We recently had a CAP inspection for our small AP only lab. We do not do IHC, only special stains (DQ, PAS, iron, etc). We were cited a phase 2 deficiency for not doing proficiency testing on our special stains. I was incredulous. We discussed the criteria for "alternative performance assessment" and I am at a loss as to how our QC does not suffice in meeting this criteria. I've been doing these inspections (inspected and inspectING) for 15 years, and have never seen PT for special stains come up once. Is this new? CAP has been about as useful as an ear on my elbow in educating me on this. anyone else have this experience? any insights anyone can offer?
CAP deficiency: Proficiency testing for special stains (WTF?)
- Thread starter ucp1980
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What is the specific requirement number they "got" you on?
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COM.1500 is alternative performance assessment (APA) requirements. However, special stains do not require APA. They require Scope of service/Analytic method which is meeting the basic requirements of Anatomic pathology (Checklist requirement ANP.21395). In this case, it's simply documenting controls are verified and recorded. No PT or APA required.
The inspector was incorrect for citing PT as a deficiency. Unfortunately, since they already cited you, you still have to file a dispute/no corrective action needed for this b.s.
