Corrective Action

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The page below is a sample from the LabCE course Inspection Preparation, Process, and Corrective Action. Access the complete course and earn ASCLS P.A.C.E.-approved continuing education credits by subscribing online.

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Corrective Action

Following the completion of the inspection process, a summation conference will be held with appropriate personnel to review the findings of the inspector(s). Staff in attendance should take notes and ask questions regarding the findings.
After the departure of the inspectors, a formal report will be provided to the designated person in the laboratory. Specifics will be provided for deficiencies or items that require correction or adjustment. The items listed may be citations or items requiring a response and/or correction or cease testing as may happen in immediate jeopardy.
  • An item noted by the inspector may have the tag of citation representing an item that is not compliant with the requirements of the surveying agency or noted as Immediate Jeopardy. There are two levels of citations issued by CMS.
    1. Standard Citations -- The cited item is out of compliance with one or more aspects of the specific regulation. A standard-level citation is less severe than a conditional-level deficiency. When a successful plan of correction is received, no revisit will occur.
    2. Conditional Citations -- A deficiency of such a nature that it limits a provider's capacity to furnish adequate care or may adversely affect a patient's health or safety. Once a successful plan of correction is received, a revisit will take place.
  • Immediate Jeopardy -- Non-compliance with one or more requirements has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Testing may be ceased with an immediate jeopardy declaration.
  • Alternately, recommendations may be provided. Recommendations refer to workplace practices or items that may be handled more efficiently or adjusted to align more with the expectations of the inspecting agency but that do not constitute a citation. Corrective action will not be required on recommendations.
  • Rarely a cease testing order can be issued for a specific test or analyte. A cessation of testing is put in place when an issue is at risk of endangering patients, is a recurrent failure, or is due to repeated proficiency testing failures.