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From:"Hagerty, Marjorie A." <>
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I have gone through many CAP inspections and have also been on inspection

It is hard to compare how one lab will do on a CAP inspection compared to
another because it is so dependent on who makes up the inspection team.
However, if you want to have a deficiency-less result, then you need to
follow the checklist exactly. If it states something, than you need to do it
exactly and record it. Any inspector can hold you to the "letter" of the
question if they so choose. (Most are very reasonable in my experience.)
There is an option of appealing, but you better have a good case.

For example: We had our CAP inspection two weeks ago. My area had no
deficiencies. However, the lab general (the lab as a whole)received a
deficiency for not monitoring the humidity. The standard says: "Are the room
temperature and humidity adequately controlled in all seasons"? It did not
occur to anyone on the safety committee to measure the humidity when we
reviewed this standard and there are 8 of us. Partially because we are the
driest desert area in the country and have no problems with humidity; some
years we get less than 1 inch of rainfall. We have been inspected many times
and this never came up nor was it ever discussed.

We immediately ordered a hand-held humidity monitor. Maybe it is something
that would have benefited us before - who knows, nobody seems to think so
here - all I know is we will do it now because the lab management would
really like no deficiencies and my eval reflects my ability to meet
inspection guidelines. Also, we invite the hospital administrator to the
summation conference and I really don't want to have deficiencies announced
in my area of responsibility.   

I have a suggestion from personal experience. If you are in doubt about the
interpretation of any question on the check-list:
Call the CAP and an expert on your checklist will answer your question. You
can always take down the name of person you spoke to and the date in case a
future inspector questions why you do something a particular way. 

Please note: We do not take temperatures on Sunday - I will be looking into

Hope this helps.
Marg Hagerty H.T. (ASCP)H.T.L., Q IHC
Supervisor, Anatomic Pathology
Eisenhower Medical Center
39-000 Bob Hope Drive
Rancho Mirage, CA 92270

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