Re: CAP Inspection - P.S.

From:Joe Nocito

We have all our current monthly QC charts in a folder. At the end of the month, all the sheets are taken out and sent to the medical director for review. Once we get the sheets back, signed, we place them in individual folders.  I have the folders set up by our CAP on site inspection dates and they are kept in the active file for those two years (I have currently 2003-2004 folders in use now).  After the year is over (in this case, 2005) I keep them in a file for an additional two years.  CAP may not go back two years, but CLIA will.  I just had a CLIA inspection and the inspector went back exactly two years from the date of the inspection.  I might be a little overboard on this, but it beats getting cited.
Joe Nocito BS, HT (ASCP) QIHC
Histology Manager
Pathology Reference Lab
San Antonio, Texas
----- Original Message -----
Sent: Friday, June 13, 2003 5:46 PM
Subject: CAP Inspection - P.S.

We are a very small histology lab and keep our temperature charts, daily equipment checks, etc. in one binder.  Should we be tape these charts over/near every instrument or is the binder sufficient?  I've been through many JCAH inspections and this was OK but this will be the first CAP.   Thanks for all your responses !

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