In this solo episode of LabReflex, Dr. Chris Zahner continues building the Lab Inspection Playbook with a practical look at common laboratory deficiencies. The point is not just to memorize a list of citations. The more useful question is why the same categories keep showing up across CAP, CLIA, COLA, Joint Commission, and other inspection frameworks.
The central idea: common deficiencies are where the lab’s documented system separates from its real operating system. They are predictable drift points. Competency becomes paperwork. Procedures fall behind practice. Proficiency testing becomes a score instead of a learning system. Maintenance logs get completed but not reviewed. Method comparisons are missed because the operation changed faster than the quality system. Director oversight becomes formal instead of functional.
1. Competency assessment
Competency assessment is one of the most consistent deficiency themes across inspection programs. The key issue is not simply whether a form was completed. It is whether the lab can show credible evidence that a person can actually perform the test system correctly, recognize when something is wrong, and respond appropriately. Training is not competency. A quiz alone is not competency. A signature is not competency.
Competency matters because it is one of the lab’s core safety systems. If a lab treats it as an annual paperwork ritual, it misses the point. A meaningful competency process should connect to real work, including routine testing, QC, maintenance, result reporting, and problem-solving.
Links:
CAP 2022 Top 10 Deficiencies: https://documents.cap.org/documents/Accreditation_2022_Top_10_Deficiencies.pdf
ASCLS Common Laboratory Deficiencies: https://ascls.org/common-laboratory-deficiencies-and-ways-to-avoid-them/
2. Procedure manuals and procedure reality
Procedure manuals are one of the clearest ways inspectors can see whether the lab’s written system matches actual bench practice. A procedure is not supposed to be a static document sitting in a folder. It should describe how the lab actually works. When the SOP says one thing, staff explain another thing, and the bench process works a third way, the lab no longer has a controlled process. It has institutional memory.
This is why inspection readiness is not binder readiness. It is reality alignment. The question is not just, “Does the procedure exist?” The question is, “Does the procedure match current practice, and can staff use it when something goes wrong?”
Links:
CMS 2024 CLIA Top Ten Deficiencies: https://www.cms.gov/regulations-and-guidance/legislation/clia/downloads/cliatopten.pdf
CAP Laboratory Quality Improvement Ideas From CAP Inspections: https://documents.cap.org/documents/CAP_Laboratory-Quality-Improvement-Ideas-From-CAP-Inspections_Apr-25-23.pdf
3. Proficiency testing
Proficiency testing is not just about passing. It is one of the lab’s external reality checks. PT asks whether the lab is getting the same answer others would get, whether the testing system is performing as expected, and whether failures or trends are being recognized and addressed.
The problem is that PT can become clerical: receive, test, submit, file, move on. But inspectors are often looking at the review process. Who reviewed it? Was anything unacceptable? Was there a trend? Was corrective action meaningful? PT is not just a grading event. It is a learning system.
Links:
CMS CLIA Proficiency Testing Brochure: https://www.cms.gov/files/document/clia-brochure-proficiency-testing-and-pt-referral-october-2024.pdf
CMS 2024 CLIA Top Ten Deficiencies: https://www.cms.gov/regulations-and-guidance/legislation/clia/downloads/cliatopten.pdf
4. Maintenance, function checks, temperatures, storage, and reagents
This is the boring operational category that reveals a lot about laboratory culture. Maintenance records, function checks, temperature logs, expired reagents, storage conditions, and equipment review are rarely conceptually difficult. They are difficult because they require reliable rhythm. The lab has to do the work, document the work, review the work, and respond when something is out of range.
A log without a response pathway is not a quality system. It is just a diary. The inspection question is not only, “Did you record the number?” It is, “What happens when the number is wrong?”
Links:
CAP Laboratory Quality Improvement Ideas From CAP Inspections: https://documents.cap.org/documents/CAP_Laboratory-Quality-Improvement-Ideas-From-CAP-Inspections_Apr-25-23.pdf
CMS 2024 CLIA Top Ten Deficiencies: https://www.cms.gov/regulations-and-guidance/legislation/clia/downloads/cliatopten.pdf
5. Method verification, AMR, and comparability
Method verification, analytical measurement range, and comparability are more technical, but they are common because labs change constantly. New instruments come in. Backup analyzers are added. Tests move between platforms. Point-of-care testing expands. Reagent lots change. Send-out tests come in-house. Each change may create a new obligation to verify, compare, document, or review.
The deeper problem is that labs often change faster than their quality systems. Every new method, instrument, backup process, or alternate pathway creates a new obligation to prove that results remain reliable.
Links:
ADLM Top Laboratory Deficiencies Across Accreditation Agencies: https://myadlm.org/cln/articles/2018/july/top-laboratory-deficiencies-across-accreditation-agencies
CAP Laboratory Quality Improvement Ideas From CAP Inspections: https://documents.cap.org/documents/CAP_Laboratory-Quality-Improvement-Ideas-From-CAP-Inspections_Apr-25-23.pdf
6. Personnel qualifications and director oversight
Personnel qualifications and director oversight connect common deficiencies to the larger issue of laboratory leadership. The lab director, technical supervisor, general supervisor, technical consultant, and other required roles are not just names on paper. They are part of the lab’s control structure. They help ensure people are qualified, PT is reviewed, procedures are appropriate, test systems are verified, and quality issues are addressed.
Many deficiencies look like documentation problems on the surface, but underneath they are ownership problems. Who owns competency? Who owns PT review? Who owns method comparability? Who owns corrective action follow-up? If nobody clearly owns the process, the proce...
