Tenn. Comp. R. & Regs. 1200-06-03-.09 - QUALITY CONTROL

(1) Condition: General Quality Control - The laboratory must establish and follow written quality control procedures, including but not limited to electronic quality control and internal quality control, for monitoring and evaluating the quality of the analytical testing process of each method. General quality control shall assure the accuracy and reliability of patient test results and reports. The medical laboratory director shall review all general quality control or may designate, in writing, the review to personnel meeting the qualification of those respective positions. The medical laboratory director shall retain the ultimate responsibility for the general quality control of the operation of the laboratory. In addition, the laboratory must meet the applicable standards in paragraphs 1200-06-03-.09(2) through 1200-06-03-.09(11) of this rule.

(2) Standard: Laboratory Testing: For each test performed, the laboratory will be in compliance if it

(a) Meets all applicable quality control requirements specified in this rule; or

(b) Follows manufacturer's instructions when using their products (instruments, kits, or test systems). In addition, the laboratory must comply with requirements within any paragraph of this rule that are unique to the laboratory facility and cannot be met by manufacturer's instructions.

(3) Standard: Test Methods, Equipment, Instrumentation, Reagents, Materials, and Supplies. The laboratory must utilize test methods, equipment instrumentation, reagents, materials, and supplies that provide accurate and reliable test results and test reports.

(a) Test methodologies and equipment must be selected and testing performed in a manner that provides test results within the laboratory's stated performance specifications for each test method as determined under Rule 1200-06-03-.09(4).

1. The laboratory must have appropriate and sufficient equipment, instruments, reagents, materials, and supplies for the type and volume of testing performed and for the maintenance of quality during all phases of testing.

2. The accuracy of analytical balance weights must be verified annually against appropriate standard sources.

3. The accuracy of thermometers must be verified annually against appropriate standard sources or following the manufacturer's instructions.

4. The accuracy of pipettes must be verified annually against appropriate standard sources or following the manufacturer's instructions.

5. The accuracy of centrifuge(s) must be verified annually against appropriate standard sources or following manufacturer's instructions.

6. The accuracy of timers must be verified annually against, appropriate standard sources or following manufacturer's instructions.

(b) The laboratory must define criteria for those conditions that are essential for proper storage of reagents and specimens, for accurate and reliable test system operation, and for test result reporting.

1. These conditions include, if applicable, the following:

(i) Water quality;

(ii) Temperature;

(iii) Humidity; and

(iv) Protection of equipment and instrumentation from fluctuations and interruptions in electrical current that adversely affect patient test results and test reports.

2. Remedial actions taken to correct conditions that fail to meet the criteria specified in this subparagraph must be documented.

(c) Reagents, solutions, culture media, control materials, calibration materials and other supplies, as appropriate, must be labeled to indicate the following:

1. Identity and, when significant, titer, strength or concentration;

2. Recommend storage requirements;

3. Preparation and expiration date;

4. The date of receipt and date opened; and

5. Other pertinent information required for proper use.

(d) Reagents, solutions, culture media, control materials, calibration materials and other supplies must be prepared, stored, and handled in a manner to ensure the following:

1. Reagents, solutions, culture media, controls, calibration materials and other supplies are not used when they have exceeded their expiration date or when they have deteriorated or are of substandard quality. The laboratory must comply with the FDA product dating requirements of 21 CFR 610.53 for blood products and other biologicals, and with the labeling requirement of 21 CFR 809.10 for all other in-vitro diagnostics. Any exception to the product dating requirements in 21 CFR 610.53, will be granted by the FDA in the form of an amendment of the product license, in accordance with 21 CFR 610.53(d). All exceptions must be documented by the laboratory; and

2. Components of reagent kits of different lot numbers are not interchanged unless otherwise specified by the manufacturer.

(4) Standard: Procedure Manual.

(a) A written procedure manual for the performance of all analytical methods used by the laboratory must be readily available and followed by laboratory personnel. Textbooks may be used as supplements to these written descriptions but may not be used in lieu of the laboratory's written procedures for testing or examining specimens. Procedure should be substantially in compliance with the CLSI, GP-2A, current version, or any subsequent version.

(b) The procedure manual must include, when applicable to the test procedure, all of the following:

1. Requirements for specimen collection and processing, and criteria for specimen rejection;

2. Procedures for microscopic examination, including the detection of inadequately prepared slides;

3. Step-by-step performance of the procedure, including test calculations and interpretation of results;

4. Preparation of slides, solutions, calibrators, controls, reagents, stains and other materials using in testing;

5. Calibration and calibration verification procedures;

6. The reportable range for patient test results as established or verified in Rule 1200-06-03-.09(5);

7. Control procedures;

8. Remedial action to be taken when calibration or control results fail to meet the laboratory's criteria for acceptability;

9. Limitations in methodologies, including interfering substances;

10. Reference range (normal values);

11. Imminent life-threatening laboratory results or "critical values";

12. Current pertinent literature references;

13. Appropriate criteria for specimen storage and preservation to ensure specimen integrity until testing is completed;

14. The laboratory's system for reporting patient results including when appropriate, the protocol for reporting critical values;

15. Description of the course of action to be taken in the event that a test system becomes inoperable; and

16. Criteria for the referral of specimens including procedures for specimen submission and handling as described in Rule 1200-06-03-.07(1)(a).

(c) Manufacturers' package inserts or operator manuals may be used, when applicable, to meet the requirements of parts (b)1. through (b) 13. of this paragraph. Information not provided by the manufacturer must be provided by the laboratory.

(d) Procedures must be re-approved, signed and dated by the medical laboratory director or designee.

(e) Procedures must be re-approved, signed and dated if the directorship of the laboratory changes.

(f) Each change in a procedure must be approved, signed, and dated by the current medical laboratory director or his or her designee approved, in writing, by the medical laboratory director.

(g) The laboratory must maintain a copy of each procedure with the dates of initial use and discontinuance. These records must be retained for two (2) years after a procedure has been discontinued.

(5) Standard: Establishment and Verification of Method Performance Specifications. Prior to reporting patient test results, the laboratory must verify or establish, for each method, the performance specifications for the following performance characteristics: accuracy; precision; analytical sensitivity and specificity, if applicable; the reportable range of patient test results; the reference range(s) (normal values); and any other applicable performance characteristic.

(a) The provisions of this section are not retroactive.

(b) A laboratory that introduces a new procedure for patient testing must, prior to reporting patient test results:

1. Verify or establish for each method the performance specifications for the following performance characteristics, as applicable:

(i) Accuracy;

(ii) Precision;

(iii) Analytical sensitivity;

(iv) Analytical specificity to include interfering substances;

(v) Reportable range of patient test results;

(vi) Reference range(s); and

(vii) Any other performance characteristic required for test performance.

2. Establish calibration and control procedures for patient testing as required under Rules 1200-06-03-.09(7) and 1200-06-03-.09(8), based upon the performance specifications verified or established in accordance with Rule 1200-06-03-.09(5).

(c) The laboratory must have documentation of the verification or establishment of all applicable test performance specifications.

(6) Standard: Equipment Maintenance and Function Checks - The laboratory must perform equipment maintenance and function checks to assure accurate and reliable test results and reports. This includes electronic, mechanical and operational checks of equipment, instruments, and test systems necessary for proper test performance and test result reporting.

(a) Maintenance of equipment, instruments, and test systems - For equipment, instruments or test systems the laboratory must:

1. Establish a maintenance protocol that ensures equipment, instrument, and test system performance necessary for accurate and reliable test results and test result reporting;

2. Perform maintenance with at least the frequency specified in the above-mentioned maintenance protocol; and

3. Document all maintenance performed.

(b) Function checks of equipment, instruments, and test systems - For equipment, instruments, or test systems the laboratory must:

1. Define a function check protocol that ensures equipment, instrument, and test system performance necessary for accurate and reliable test results and test result reporting;

2. Perform function checks including background or baseline checks as specified in the above-mentioned function check protocol. Function checks must be within the laboratory's established limits before patient testing is conducted; and

3. Document all function checks performed.

(7) Standard: Calibration and Calibration Verification Procedures - Calibration and calibration verification procedures are required to substantiate the continued accuracy of the test method throughout the laboratory's reportable range for patient test results. Calibration is the process of testing and adjusting an instrument kit, or test system to provide a known relationship between the measurement response and the value of the substance that is being measured by the test procedure. Calibration verification is the assaying of calibration materials in the same manner as patient samples to confirm that the calibration of the instrument, kit, or test system has remained stable throughout the laboratory's reportable range for patient test results. The reportable range for patient test results is the range of test result values over which the laboratory can establish or verify the accuracy of instrument, kit or test system measurement response. Calibration and calibration verification must be performed and documented as required in this rule unless otherwise specified in paragraphs 1200-06-03-.09(12) through 1200-06-03-.09(34). For each method the laboratory must:

(a) Perform calibration procedures

1. At a minimum, in accordance with manufacturer's instructions, if provided, using calibration materials provided or specified, as appropriate, and with at least the frequency recommended by the manufacturer;

2. In accordance with criteria established by the laboratory.

(i) Including the number, type and concentration of calibration materials, acceptable limits for calibration, and the frequency of calibration if manufacturer's instructions are not provided; and

(ii) Using calibration materials appropriate for the methodology and, if possible, traceable to a reference method or reference material of known value; and

3. Whenever calibration verification fails to meet the laboratory's acceptable limits for calibration verification; and

(b) Perform calibration verification procedures

1. In accordance with the manufacturer's calibration verification instructions when they meet or exceed the requirements specified by the laboratory as described in Rule 1200-06-03-.09(7)(b) 2., or

2. In accordance with criteria established by the laboratory

(i) Including the number, type, and concentration of calibration materials, acceptable limits for calibration verification and frequency of calibration verification; and

(ii) Using calibration materials appropriate for

(I) The methodology and, if possible, traceable to a reference method or reference material of known value; and

(II) Verifying the laboratory's established reportable range of patient test results, which must include at least a minimal (or zero[0]) value, a mid-point value, and a maximum value at the upper limit of that range; and

(iii) At least once every six (6) months and whenever any of the following occur:

(I) A complete change of reagents for a procedure is introduced, unless the laboratory can demonstrate that changing reagent lot numbers does not effect the range used to report patient test results, and control values are not adversely affected by reagent lot number changes.

Note: If reagents are obtained from a manufacturer and all of the reagents for a test are packaged together, the laboratory is not required to perform calibration verification for each package of reagents, provided the packages of reagents are received in the same shipment and contain the same lot number;

(II) There is major preventive maintenance or replacement of critical parts that may influence test performance;

(III) Controls reflect an unusual trend or shift or are outside of the laboratory's acceptable limits and other means of assessing and correcting unacceptable control values have failed to identify and correct the problem; or

(IV) The laboratory's established schedule for verifying the reportable range for patient test results requires more frequent calibration verification than specified in Rule 1200-06-03-.09(7)(b) 2.(i), (ii), or (iii) and

(c) Document all calibration verification procedures performed.

(8) Standard: Control Procedures - Control procedures are performed on a routine basis to monitor the stability of the method or test system; control materials provide a means to indirectly assess the accuracy and precision of patient test results. Control procedures must be performed as defined in this paragraph unless otherwise specified in paragraphs 1200-06-03-.09(12) through 1200-06-03-.09(34).

(a) Control samples must be tested in the same manner as patient specimens.

1. For qualitative tests, the laboratory must include a positive and negative control with each run of patient specimens.

2. For quantitative tests, the laboratory must include at least two (2) samples of different concentrations of either calibration materials, control materials, or a combination thereof with the frequency determined in subparagraph 1200-06-03-.09(3)(a), but not less frequently than once each run of patient specimens.

3. For electrophoretic determinations

(i) At least one (1) control sample must be used in each electrophorectic cell; and

(ii) The control sample must contain fractions representative of those routinely reported in patient specimens.

4. Each day of use, the laboratory must evaluate the detection phase of direct antigen systems using an appropriate positive and negative control material (organism or antigen extract). When direct antigen systems include an extraction phase, the system must be checked each day of use using a positive organism.

5. If calibration materials and control materials are not available, the laboratory must have an alternative mechanism to assure the validity of patient test results.

(b) Control samples must be tested in the same manner as patient specimens.

(c) When calibration or control materials are used, statistical parameters (e.g. mean and standard deviation) for each lot number of calibration material and each lot of control material must be determined through repetitive testing.

1. The stated values of an assayed control material may be used as the target values provided the stated values correspond to the methodology and instrumentation employed by the laboratory and are verified by the laboratory.

2. Statistical parameters for unassayed materials must be established over time by the laboratory through concurrent testing with calibration materials or control materials having previously determined statistical parameters.

(d) Control results must meet the laboratory's criteria for acceptability prior to reporting patient test results.

(e) Reagent and supply checks.

1. The laboratory must check each lot or shipment of reagents, discs, stains, antisera and identification systems (systems using two (2) or more substrates) when prepared or opened for positive and negative reactivity, as well as graded reactivity if applicable.

2. Each day of use (unless otherwise specified in this rule), the laboratory must test staining materials for intended reactively to ensure predictable staining characteristics.

3. The laboratory must check fluorescent stains for positive and negative reactivity each time of use (unless otherwise specified in this rule).

4. The laboratory must check each batch or shipment of media for sterility, if it is intended to be sterile and if sterility is required for testing. Media must also be checked for its ability to support growth, and as appropriate, selectivity/inhibition and/or biochemical response. The laboratory may use manufacturer's control checks of media provided the manufacturer's product insert specifies that the manufacturer's quality control checks meet the current standards of the Clinical and Laboratory Standards Institute (CLSI) for media quality control. The laboratory must document that the physical characteristics of the media are not compromised and report any deterioration in the media to the manufacturer. The laboratory must follow the manufacturer's specifications for using the media and be responsible for the test results.

5. A batch of media (solid, semi-solid, or liquid) consists of all tubes, plates, or containers of the same medium prepared at the same time and in the same laboratory, or, if received from an outside source of commercial supplier, consists of all of the plates, tubes or containers of the same medium that have the same lot numbers and are received in a single shipment.

(f) For each method that is developed in-house, that is a modification of the manufacturer's test procedure, the laboratory must evaluate instrument and reagent stability and operator variance in determining the number, type, and frequency of testing calibration or control materials and establish criteria for acceptability used to monitor test performance during a run of patient specimen(s). A run is an interval within which the accuracy and precision of a testing system is expected to be stable, but cannot be greater than twenty-four (24) hours or less than the frequency recommended by the manufacturer. For each procedure, the laboratory must monitor test performance using calibration materials or a combination thereof.

(9) Standard: Remedial Actions - Remedial action policies and procedures must be established by the laboratory and applied as necessary to maintain the laboratory's operation for testing patient specimens in a manner that assures accurate and reliable patient test results and reports. The laboratory must document all remedial actions taken when any of the following occur:

(a) The laboratory shall take any remedial action to correct a noted error in specimen collection or loss of specimen.

(b) Test systems that do not meet the laboratory's established performance specifications, as determined in Rule 1200-06-03-.09(5) include but are not limited to the following:

1. Equipment or methodologies that perform outside of established operating parameters or performance specifications;

2. Patient test values that are outside of the laboratory's reportable range of patient test results; and

3. The determination that the laboratory's reference range for a test procedure is inappropriate for the laboratory's patient population.

(c) Results of control and calibration materials that fail to meet the laboratory's established criteria for acceptability. All patient test results obtained in the unacceptable test run or since the last acceptable test run must be evaluated to determine if patient test results have been adversely affected. The laboratory must take the remedial action necessary to ensure the reporting of accurate and reliable patient test results;

(d) If the laboratory cannot report patient test results within its established time frames the laboratory must determine, based on the urgency of the patient test(s) requested, the need to notify the appropriate individual of the delayed testing; and

(e) Errors in the reported patient test results are detected. The laboratory must

1. Promptly notify the authorized person ordering or individual utilizing the test results of reporting errors;

2. Issue corrected reports promptly to the authorized person ordering the test or the individual utilizing the test results; and

3. Maintain exact duplicates of the original report as well as the corrected report for two (2) years.

(f) There must be a procedure of review in operation to verify highly unusual results such as delta values and critical values. This review must be performed and documented by the supervisor or other person designated in writing on a daily basis to identify possibly erroneous tests.

(10) Standard: Quality Control Records - The laboratory must document and maintain records of all quality control activities specified in paragraphs 1200-06-03-.09(2) through 1200-06-03-.09(34) and retain records for at least two (2) years. Immunohematology quality control records must be maintained for a period of no less than five (5) years. In addition, quality control records for blood and blood products must be maintained for a period not less than five (5) years. In addition, quality control records for blood and blood products must be maintained for a period not less than five (5) years after processing records have been completed, or six (6) months after the latest expiration date, whichever is the later date, in accordance with 21 CFR 6060.160(d).

(11) Condition: Quality Control - Specialties and Subspecialties - The laboratory must establish and follow written policies and procedures for an acceptable quality control program that include verification and assessment of accuracy, measurement of precision and detection of error for all analyses and procedures performed by the laboratory. In addition to the general requirements specified in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11), the laboratory must meet the applicable requirements of paragraphs 1200-06-03-.09(12) through 1200-06-03-.09(34) or an CMS approved equivalent procedure and the following:

(a) Meets quality control requirements specified in this paragraph; or

(b) Follows manufacturer's instructions when using products (instruments, kits, or test systems) as well as specialty and subspecialty quality control.

(c) Failure to meet any of the applicable conditions in paragraph 1200-06-03-.09(12) through 1200-06-03-.09(34) may result in revocation of licensure for the entire specialty or subspecialty to which the condition applies, in accordance with Rule 12-6-3-.05.

(12) Condition: Microbiology - The laboratory must meet the applicable quality control requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and in paragraphs 1200-06-03-.09(13) through 1200-06-03-.09(17) for the subspecialties for which it is certified under the specialty of microbiology.

(13) Condition: Bacteriology - To meet the quality control requirements for bacteriology in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and in paragraphs 1200-06-03-.09(13) through 1200-06-03-.09(17) for the subspecialties for which it is certified under the specialty of microbiology.

(a) The laboratory must check positive and negative reactivity with control organisms as specified below:

1. Each day of use for catalase, coagulase, beta-lactamase, and oxidase reagents and DNA probes;

2. Each week of use for Gram and acid-fast stains, bacitracin, optochin, ONPG, X and V discs or strips; and

3. Each month of use for antisera.

(b) Each week of use, the laboratory must check XV discs or strips with a positive control organism.

(c) For antimicrobial susceptibility tests, the laboratory must check each new batch of media and each lot of antimicrobial discs before, or concurrent with, initial use, using approved reference organisms.

1. The laboratory's zone sizes or minimum inhibitory concentration for reference organisms must be within established limits before reporting patient results.

2. The laboratory must use the appropriate control organism(s) to check the procedure as required by current law under CLIA.

(14) Condition: Mycobacteriology - To meet the quality control requirements for mycobacteriology, the laboratory must comply with the applicable requirements in paragraph 1200-06-03-.09 (1) through 1200-63-.09(11) and with subparagraphs (a) through (d) of this paragraph. All quality control activities must be documented.

(a) Each day of use, the laboratory must check the iron uptake test with at least one (1) acid-fast organism that produces a positive reaction and with an organism that produces a negative reaction and check all other reagents or test procedures used for mycobacteria identification with at least one (1) acid-fast organism that produces a positive reaction.

(b) The laboratory must check flurochrome acid-fast stains for positive and negative reactivity each week of use.

(c) The laboratory must check acid-fast stains each week of use with an acid-fast organism that produces a positive reaction.

(d) For susceptibility tests performed on Mycobacterium tuberculosis, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and with subparagraphs (a) through (d) of this paragraph. All quality control activities must be documented.

(15) Condition: Mycology - To meet the quality control requirements for mycology, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) though 1200-06-03-.09(11) and with subparagraphs (a) through (d) of this paragraph. All quality control activities must be documented.

(a) Each day of use, the laboratory using the auxanographic medium for nitrate assimilation must check the nitrate reagent with a peptone control.

(b) Each week of use, the laboratory must check all reagents used with biochemical tests and other test procedures for mycological identification with an organism that produces a positive reaction.

(c) Each week of patient testing, the laboratory must check acid-fast stains for positive and negative reactivity.

(d) For susceptibility tests, the laboratory must test each drug each day of use with at least one (1) control strain that is susceptible to the drug. The laboratory must establish control limits. Criteria for acceptable control results must be met prior to reporting patient results.

(16) Condition: Parasitology - To meet the quality control requirements for parasitology, the laboratory must comply with the applicable requirements of paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and with subparagraphs (a) through (c) of this paragraph. All quality control activities must be documented.

(a) The laboratory must have available a reference collection of slides or photographs, and, if available, gross specimens for identification of parasites and must use these references in the laboratory for appropriate comparison with diagnostic specimens.

(b) The laboratory must calibrate and use the calibrated ocular micrometer for determining the size of ova and parasites, if size is a critical parameter. Recalibration must be performed if the ocular micrometer is moved to another microscope or objectives are changed.

(c) Each month of use, the laboratory much check permanent stains using a fecal sample control that will demonstrate staining characteristics.

(17) Condition: Virology - To meet the quality control requirements for virology, the laboratory must comply with the applicable requirements in paragraph 1200-06-03-.09(1) through 1200-06-03-.09(11) and with subparagraphs (a) through (c) of this paragraph. All quality control activities must be documented.

(a) The laboratory must have available host systems for the isolation of viruses and test methods for the identification of viruses that cover the entire range of viruses that are etiologically related to clinical diseases for which services are offered.

(b) The laboratory must maintain records that reflect the systems used and the reactions observed.

(c) In tests for the identification of viruses, the laboratory must simultaneously culture uninoculated cells or cell substrate control as a negative control to detect erroneous identification results.

(18) Condition: Diagnostic Immunology - The laboratory must meet the applicable quality control requirements in paragraph 1200-06-03-.09(1) through 1200-06-03-.09(11) and paragraphs 1200-3-.09(19) through 1200-06-03-.09(20) for the subspecialties for which it is certified under the specialty of diagnostic immunology.

(19) Condition: Syphilis Serology - To meet the quality control requirements for syphilis serology, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and with subparagraphs (a) through (c) of this paragraph. All quality control activities must be documented.

(a) For laboratories performing syphilis testing, the equipment, glassware, reagents, controls, and techniques for tests for syphilis must conform to manufacturers' specifications.

(b) The laboratory must run serologic tests on patient specimens concurrently with a positive serum control of known titer or controls of graded reactivity plus a negative control.

(c) The laboratory must employ positive and negative controls that evaluate all phases of the test system to ensure reactivity and uniform dosages.

(d) The laboratory may not report test results unless the predetermined reactivity pattern of the controls is observed.

(e) All facilities manufacturing blood and blood products for transfusion or serving as referral laboratories for these facilities must meet the syphilis serology testing requirements of 21 CFR 640.5(a).

(20) Condition: General Immunology - To meet the quality control requirements for general immunology, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and with subparagraphs (a) through (d) of this paragraph. All quality control activities must be documented.

(a) The laboratory must run serologic tests on patient specimens concurrently with a positive serum control of know titer or controls of graded reactivity and uniform dosages when positive and negative controls are not sufficient.

(b) The Laboratory must employ controls that evaluate all phases of the test system (antigens, complement, erythrocyte indicator systems, etc.) to ensure reactivity and uniform dosages when positive and negative controls alone are not sufficient.

(c) The laboratory may not report test results unless the predetermined reactivity pattern of the controls is observed.

(d) All facilities manufacturing blood and blood products for transfusion or serving as referral laboratories for these facilities must meet

1. The HIV testing requirements of 21 CFR 610.45; and

2. Hepatitis testing and requirements of 21 CFR 610.40.

(21) Condition: Chemistry - The laboratory must meet the applicable quality control requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and paragraphs 1200-06-03-.09(22) through 1200-06-03-.09(24) for the subspecialties for which it is certified under the specialty of chemistry.

(22) Condition: Routine Chemistry - To meet the quality control requirements for routine chemistry, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11). All quality control activities must be documented. In addition, for blood gas analyses, the laboratory must:

(a) Calibrate or verify calibration according to the manufacturer's instructions and with at least the frequency recommended by the manufacturer;

(b) Test one (1) sample of control material for each eight (8) hours of testing or as set out in the manufacturer's instructions;

(c) Use a combination of calibrators and control materials that include both low and high values on each day of testing or as set out in the manufacturer's instruction; and

(d) Include one (1) sample of calibration material or control material each time patients are tested unless automated instrumentation internally verifies calibration at least every thirty (30) minutes or as set out in the manufacturer's instruction.

(23) Condition: Endocrinology - To meet the quality control requirements for endocrinology, the laboratory must comply with the applicable requirements contained in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11). All quality control activities must be documented.

(24) Condition: Toxicology - To meet the quality control requirements for toxicology, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11). However, this subsection shall not apply to drug testing for employment purposes. All quality control activities must be documented. In addition, for drug abuse screening using thin layer chromatography:

(a) Each plate must be spotted with at least one (1) sample of calibration material containing all drug groups identified by thin layer chromatography which the laboratory reports; and

(b) At least one (1) control sample must be included in each chamber, and the control sample must be processed through each step of patient testing, including extraction procedures.

(25) Condition: Hematology - To meet the quality control requirements for hematology, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and with subparagraphs (a) through (d) of this paragraph. All quality control activities must be documented.

(a) For automated hematology testing systems, excluding coagulation, the laboratory must include two (2) levels of controls for each twenty-four (24) hours of operation.

(b) For all automated coagulation testing systems, the laboratory must include two (2) levels of control for each eight (8) hours of operation and each time a change in reagents occurs.

(c) For manual hemoglobin determinations (cyanmethemoglobin), the procedure must be standardized with reference materials of known, certified values. At least four (4) different hemoglobin concentrations must be used to prepare the calibration curve or to calibrate the readout instruments. For procedures using calibration curves, all curves must be repeated regularly and verified after serving or recalibration of instruments. Photometer functions checks must be run and recorded daily. Photometers must be checked for linearity periodically and when instrument adjustments have been made with appropriate filters or solutions.

(d) For manual hematocrit determinations, the speed and timer of the microhematocrit centrifuge must be checked at specific intervals. The constant packing time (minimum spin to reach maximum packing of cells) must be assessed on installation and reassessed when there has been a change in either the speed or time.

(26) Condition: Pathology - The laboratory must meet the applicable quality control requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and paragraphs 1200-06-03-.09(27) through 1200-06-03-.09(29) for the subspecialties; for which it is certified under the specialty of pathology. All quality control activities must be documented.

(27) Condition: Cytology - To meet the quality control requirements for cytology, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and subparagraphs (a) through (g) of this paragraph.

(a) The laboratory must assure that

1. All gynecologic smears are stained using a Papanicolaou or modified Papanicolaou staining method;

2. Effective measures are taken to prevent cross-contamination between gynecologic and nongynecologic specimens during the staining process;

3. Nongynecologic specimens that have a high potential for cross-examination are stained separately from other nongynecologic specimens, and the stains are filtered or changed following staining;

4. Diagnostic interpretations are not reported on unsatisfactory smears; and

5. All cytology slide preparations are evaluated on the premises of a laboratory certified to conduct testing in the subspecialty of cytology.

(b) The laboratory is responsible for ensuring the following:

1. Each individual engaged in the evaluation of cytology preparations by nonautomated microscopic technique examines no more than one hundred (100) slides (one patient per slide, gynecologic or nongynecologic, or both) in a twenty-four (24) hour period, irrespective of the site or laboratory. This limit represents an absolute maximum number of slides and is not being employed as a performance target for each individual. Previously examined reactive , reparative, atypical, premalignant or malignant gynecologic cases as defined in part (c)1. of this paragraph, previously examined nongynecologic cytology preparations, and tissue pathology slides examined by a pathologist are not included in the one hundred (100) slide limit.

2. For purposes of workload calculations, each slide preparation (gynecologic or nongynecologic) made using automated, semi-automated, or other liquid-based slide preparatory techniques which result in cell dispersion over one-half (1/2) or less of the total available slide area and which is examined by nonautomated microscopic technique counts as one-half (1/2) slide.

3. Records are maintained of the total number of slides examined by each individual during each twenty-four (24) hour period, irrespective of the site or laboratory, and the number of hours each individual spends examining slides in the twenty-four (24) hour period; and

(i) The maximum number of one hundred (100) slides described in part (b)1. of this paragraph may not be examined in less than an eight (8) hour workday, and

(ii) For the purposes of establishing workload limits for individual examining slides by nonautomated microscopic technique on other than an eight (8) hour workday basis (includes full-time employees with duties other than slide examination and part-time employees), a period of eight (8) hours must be used to prorate the number of slides that may be examined. The following formula shall be used to determine maximum slide volume to be examined:

(iii) (Number of hours examining slides x 100) - 8

(c) A pathologist must ensure the following:

1. All gynecologic smears interpreted to be showing reactive or reparative changes, atypical squamous or glandular cells of undetermined significance, or to be in the premalignant (dysplasia, cervical intraepithelial neoplasia or all squamous intraepithelial lesions including human papillomavirus-associated changes) or malignant category are confirmed by a pathologist qualified by certification in anatomic pathology by the American Board of Pathology. The report must be signed to reflect the review or, if a computer report is generated with signature, it must reflect an electronic signature authorized by the pathologist;

2. All nongynecologic cytologic preparation are reviewed by the pathologist. The report must be signed to reflect the pathologist's review or, if a computer report is generated with signature, it must reflect an electronic signature authorized by the pathologist;

3. The slide examination performance of each cytotechnologist is evaluated and documented, including performance evaluation through the reexamination of normal and negative cases and feedback on the reactive, reparative, a typical, malignant or premalignant cases as defined in part (c)1. of this paragraph; and

4. A maximum number of slides, not to exceed the maximum workload limit described in subparagraph (b) of this paragraph is established by the pathologist for each individual examining slide preparations by nonautomated microscopic technique.

(i) The actual workload limit must be documented for each individual and established in accordance with the individual's capability based on the performance evaluation as described in part (c) 3. of this paragraph.

(ii) Records are available to document that each individual's workload limit is reassessed at least every six (6) months and adjusted when necessary.

(d) The laboratory must establish and follow a program designed to detect errors in the performance of cytologic examinations and the reporting of results.

1. The laboratory must establish a program that includes a review of slides from at least ten per cent (10%) of the gynecologic cases interpreted to be negative for reactive, reparative, atypical premalignant or malignant conditions as defined in part (c) 1. This review must be done by a pathologist qualified by certification in anatomic pathology by the American Board of Pathology, a cytology general supervisor qualified under Rule 1200-06-01-.23 or a cytotechnologist qualified under Rule 1200-06-01-.24.

(i) The review must include negative cases selected at random from the total caseload and from patients or groups of patients that are identified as having a high probability of developing cervical cancer, based on available patient information;

(ii) Records of initial examinations and rescreening results must be available; and

(iii) The review must be completed before reporting patient results on those cases selected.

2. The laboratory must compare clinical information, when available, with cytology reports and must compare all malignant and premalignant (as defined in part (c)1. of this paragraph) gynecology reports with the histopathology report, if available in the laboratory (either on-site or in storage), and determine the causes of any discrepancies.

3. For each patient with a current high grade intraepithelial lesion (moderate dysplasia or CIN-2 or above), the laboratory must review all normal or negative gynecologic specimens received within the previous five (5) years, if available in the laboratory (either on-site or in storage). If significant discrepancies are found that would affect patient care, the laboratory must notify the patient's physician and issue an amended report.

4. The laboratory must establish and document an annual statistical evaluation of the number of cytology cases examined, number of specimens processed by specimen type, volume of patient cases reported by diagnosis (including the number reported as unsatisfactory for diagnostic interpretation), number of gynecologic cases where cytology and available histology are discrepant, the number of gynecologic cases where any rescreen of a normal or negative specimen results in reclassification as malignant or premalignant, as defined in part (c)1. of this paragraph, and the number of gynecologic cases for which history results were unavailable to compare with malignant or premalignant cytology cases as defined in part(c)1. of this paragraph.

5. The laboratory must evaluate the case reviews of each individual examining slides against the laboratory's overall statistical values, document any discrepancies, including reasons for the deviation, and document corrective action, if appropriate.

(e) The laboratory report must:

1. Clearly distinguish specimens or smears, or both, that are unsatisfactory for diagnostic interpretation; and

2. Contain narrative descriptive nomenclature for all results.

(f) Corrected reports issued by the laboratory must indicate the basis for correction.

(g) The laboratory must retain all slide preparations for five (5) years from the date of examination, or slides may be loaned to proficiency testing programs, in lieu of maintaining them for this time period, provided the laboratory receives written acknowledgement of the receipt of slides by the proficiency testing program and maintains the acknowledgement to document the loan of such slides. Documentation for slides loaned or referred for purposes other than proficiency testing must also be maintained. All slides must be retrievable upon request.

(28) Condition: Histopathology - To meet the quality control requirements for histopathology, a laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and subparagraphs (a) through (c) of this paragraph. All quality control activities must be documented.

(a) A control slide of known reactivity must be included with each slide or group of slides for differential, or special stains. Reaction(s) of the control slide with each special stain must be documented each day of testing.

(b) The laboratory performing the histopathology testing must retain stained slides at least ten (10) years from the date of examination and retain specimen blocks at least five (5) years from the date of examination.

(c) The laboratory must retain remnants of tissue specimens in a manner that assures proper preservation of the tissue specimens until the portions submitted for microscopic examination have been examined and a diagnosis made by an individual qualified by certification in anatomic pathology by the American Board of Pathology.

(d) All tissue pathology reports must be signed by an individual qualified as specified in subparagraph (c) of this paragraph. If a computer report is generated with an electronic signature, it must be authorized by the individual qualified as specified in subparagraph (c) of this paragraph.

(e) The laboratory must utilize acceptable terminology of a recognized system of disease nomenclature in reporting results.

(29) Condition: Oral Pathology - To meet the quality control requirements for oral pathology, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and 1200-06-03-.09(28). All quality control activities must be documented.

(30) Condition: Radiobioassay - To meet quality control requirements for radiobioassay, the laboratory must comply with the applicable requirements of paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11). All quality control activities must be documented.

(31) Condition: Histocompatibility - In addition to meeting the applicable requirements for general quality control in paragraphs 1200-06-03-.09(1), for quality control for general immunology in paragraph 1200-06-03-.09(20) and for immunohematology in paragraph 1200-06-03-.09(33), the laboratory must comply with the applicable requirements in subparagraphs (a) through (d) of this paragraph. All quality control activities must be documented.

(a) For renal allotransplantation, the laboratory must meet the following requirements:

1. The laboratory must have available and follow criteria for the following:

(i) Selecting appropriate patient serum samples for crossmatching;

(ii) The technique used in crossmatching;

(iii) Preparation of donor lymphocytes for crossmatching; and

(iv) Reporting crossmatch results;

2. The laboratory must

(i) Have available results of final crossmatches before an organ or tissue is transplanted, and

(ii) Make a reasonable attempt and document efforts to have available serum specimens for all potential transplant recipients at initial typing, for periodic screening, for preptransplantation crossmatch and following sensitizing events, such as transfusion and transplant loss;

3. The laboratory's storage and maintenance of both recipient sera and reagents must

(i) Be at an acceptable temperature range for sera and components;

(ii) Use a temperature alarm system and have an emergency plan for alternate storage; and

(iii) Ensure that all specimens are properly identified and easily retrievable;

4. The laboratory's reagent typing sera inventory (applicable only to locally constructed trays) must indicate source, bleeding date and identification number, and volume remaining.

5. The laboratory must properly label and store all labile components utilized in histocompatibility testing.

6. The laboratory must:

(i) HLA type all potential transplant recipients;

(ii) Type cells from organ donors referred to the laboratory; and

(iii) Have available and follow a policy that establishes when antigen redefinition and retyping are required;

7. The laboratory must have available and follow criteria for

(i) The preparation of lymphocytes for HLA-A, B and DR typing;

(ii) Selecting typing reagents, whether locally or commercially prepared;

(iii) The assignment of HLA antigens; and

(iv) Assuring that reagents used for typing recipients and donors are adequate to define all major and International Workshop HLA-A, B and DR specificities for which reagents are readily available;

8. The laboratory must do the following:

(i) Screen potential transplant recipient sera for performed HLA-A and B antibodies with a suitable lymphocyte panel on sera collected

(I) At the time of the recipient's initial HLA typing; and

(II) Thereafter, following sensitizing events and upon request; and

(ii) Use a suitable cell panel for screening patient sera (antibody screen), a screen that contains all the major HLA specificities and common splits

(I) If the laboratory does not use commercial panels, it must maintain a list of individuals for fresh panel bleeding; and

(II) If the laboratory uses frozen panels, it must have a suitable storage system,

9. The laboratory must check

(i) Each typing tray using

(I) Positive control sera;

(II) Negative control sera; and

(III) Positive controls for specific cell types when applicable (i.e., T. cells, B cells, and monocytes); and

(ii) Each compatibility test (i.e. mixed lymphocyte cultures, homozygous typing cells or DNA analysis) and typing for disease-associated antigens using controls to monitor the test components and each phase of the test system to ensure an acceptable performance level;

10. Compatibility testing for cellularly-defined antigens must utilize techniques such as the mixed lymphocyte culture test, homozygous typing cells or DNA analysis;

11. If the laboratory reports the recipient's or donor's, or both, ABO blood group and D(Rho) typing, the testing must be performed in accordance with 1200-06-03-.09(33);

12. If the laboratory utilizes immunologic reagents (such as antibodies or complement) to remove contaminating cells during the isolation of lymphocytes or lymphocyte subsets, the efficiency of the methods must be verified with appropriate quality control procedures;

13. At least once each month, the laboratory must have each individual performing tests evaluate a previously tested specimen as an unknown to verify his or her ability to reproduce test results. Records of the results for each individual must be maintained; and

14. The laboratory must participate in at least one (1) national or regional cell exchange program, if available, or develop an exchange system with another laboratory in order to validate inter-laboratory reproducibility.

(b) If the laboratory performs histocompatibility testing for:

1. Transfusion and other non-renal transplantation, excluding bone marrow and living transplant, all the requirements specified in this paragraph, as applicable, except for the performance of mixed lymphocyte cultures, must be met;

2. Bone marrow transplantation, all the requirements specified in this paragraph, including the performance of mixed lymphocyte cultures or other augmented testing to evaluate class 11 compatibility, must be met; and

3. Non-renal solid organ transplantation, the results of final crossmatches must be available before transplantation when the recipient has demonstrated presensitization by prior serum screening except for emergency situations. The laboratory must document the circumstances, if known, under which emergency transplants are performed, and records must reflect any information concerning the transplant provided to the laboratory by the patient's physician.

(c) Laboratories performing HLA typing for disease-associated studies must meet all the requirements specified in this paragraph except for the performance of mixed lymphocyte cultures, antibody screening and crossmatching.

(d) For laboratories performing organ donor HIV testing the requirements of paragraph 1200-06-03-.09(20) for the transfusion of blood and blood products must be met.

(32) Condition: Clinical Cytogenetics - To meet the quality control requirements for clinical cytogenetics, the laboratory must comply with the applicable requirement of paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(11) and with subparagraphs (a) through (d) of this paragraph. All quality control activities must be documented.

(a) When determination of sex is performed by X and Y chromatin counts, these counts must be based on an examination of an adequate number of cells. Confirmatory testing such as full chromosome analysis must be performed for all atypical results.

(b) The laboratory must have records that reflect the media used and document the reactions observed, number of cells counted, the number of cells karyotyped, the number of chromosomes counted for each metaphase spread, and the quality of the banding that the resolution is sufficient to support the reported results; and that an adequate number of karyotypes are prepared for each patient.

(c) The laboratory also must have policies and procedures for assuring an accurate and reliable patient sample identification during the process of accessioning, cell preparation, photographing or other image reproduction technique, and photographic printing, and storage and reporting of results or photographs.

(d) The laboratory report must include the summary and interpretation of the observations and number of cells counted and analyzed and the use of recognized nomenclature, such as the International System of Cytogenetic Nomenclature.

(e) Adequate slides, films, hard copies of karyotypes and reports shall be retained for twenty (20) years.

(33) Condition: Immunohematology - To meet the quality control requirements for immunohematology, the laboratory must comply with the applicable requirements in paragraphs 1200-06-03-.09(1) through 1200-06-03-.09(II) and with subparagraphs (a) through (d) of this paragraph. All quality control activities must be documented.

(a) The laboratory must perform ABO group and D(Rho) typing, unexpected antibody detection, antibody identification and compatibility testing in accordance with manufacturer's instruction, if provided, and as applicable, with 21 CFR 606 (with the exception of 21 CFR 606.20a, Personnel) and 21 CFR 640, et. seq.

(b) The laboratory must perform ABO group by concurrently testing unknown red cells with anti-A and anti-B grouping reagents. For confirmation of ABO group, the unknown serum must be tested with known A, and B red cells.

(c) The laboratory must determine the D(Rho) type by testing unknown red cells with anti-D(anti-Rho) blood grouping reagent.

(d) If required in the manufacturer's package insert for anti-D reagents, the laboratory must employ a control system capable of detecting false positive D(Rho) test results.

(34) Condition: Transfusion services and bloodbanking - If a facility provides services for the transfusion of blood and blood products, the facility must be under the adequate control and technical supervision of a pathologist or other doctor of medicine or osteopathy meeting the qualifications in Rule 1200-6-1-.20, technical supervision in immunohematology. The facility must ensure that there are facilities for procurement, safekeeping and transfusion of blood and blood products and that blood and blood products must be available to meet the needs of the physicians responsible for the diagnosis, management, and treatment of patients. The facility meets this condition by complying with the standards in paragraphs 1200-06-03-.09(34)(a) through (f).

(a) Standard: Immunohematological collection, processing, dating periods, labeling and distribution of blood and blood products.

In addition to the requirements of parts 1. through 4. of this subparagraph, the facility must also meet the applicable quality control requirements in 1200-06-03-.09(1) through 1200-06-03-.09(10).

1. Blood and blood product collection, processing and distribution must comply with 21 CFR Part 640 and 21CFR Part 606, and the testing laboratory must meet the applicable requirements of 42 CFR Part 493.

2. Dating of blood and blood products must conform to 21 CFR 610.53.

3. Labeling of blood and blood products conform to 21 CFR Part 606, Subpart G.

4. Policies to ensure positive identification of a blood or blood product recipient must be established, documented and followed.

(b) Standard: Blood and blood product storage facilities

1. The blood and blood products must be stored under appropriate conditions, which include an adequate temperature alarm system that is checked and documented daily.

(i) An audible alarm system, including a chart recorder, must monitor proper blood and blood product storage temperature continuously.

(ii) Activation, to include high and low limits, of alarm system must be documented periodically, no less frequently than quarterly.

(iii) A remote alarm system is required if location where blood or blood products are stored is not continuously staffed.

(iv) There must be a written procedure for response to an alarm when temperature limits are exceeded.

(v) There must be a written procedure for response to an alarm indicating specific personnel to respond and their appropriate action.

2. If blood is stored or maintained for transfusion purposes outside of a monitored refrigerator, the facility must ensure and document that storage conditions, including temperature, are appropriate to prevent deterioration of the blood or blood product.

(c) Standard: Arrangement for services - In the case of services provided outside the blood bank, the facility must have an agreement reviewed and approved by the director that governs the procurement, transfer, and availability of blood and blood products.

(d) Standard: Provision of testing - There must be provision for prompt ABO blood group, D(Rho) type, unexpected antibody detection and compatibility testing in accordance with 1200-06-03-.09(34) of this rule and the laboratory investigation of transfusion reactions, either through the facility or under arrangement with an approved facility on a continuous basis, under the supervision of a pathologist or other doctor of medicine or osteopathy meeting the qualifications of 1200-06-01-.20.

(e) Standard: Retention of samples of transfused blood and patient specimens.

1. Samples of each unit of transfused blood and the patient specimens must be retained for a minimum of seven (7) days for further testing in the event of reactions according to the facility's established procedures.

2. The facility must promptly dispose of blood not retained for further testing that has passed its expiration date.

(f) Standard: Investigation of transfusion reactions.

1. The facility, according to its established procedures, must promptly investigate all transfusion reactions occurring in all facilities for which it has investigational responsibility and make recommendations to the medical staff regarding improvements in transfusion procedures.

2. The facility must document that all necessary remedial actions are taken to prevent future recurrence of transfusion reactions and that all policies and procedures are reviewed to assure that they are adequate to ensure the safety of individuals being transfused within the facility.

3. When a fatality occurs as a result of a complication of blood or blood component transfusions, the Director, Office of Compliance and Biologics Quality, Center for Biological Evaluation and Research (CBER), FDA, must be notified within twenty-four (24) hours. Within seven (7) days after the fatality, a written report of the investigation must be submitted to the Director at 1401 Rockville Pike, Suite 200 N, Rockville, MD 20852-1448. A copy of the report should be sent to the collecting facility if appropriate. See AABB Accreditations Requirements Manual.

Notes

Tenn. Comp. R. & Regs. 1200-06-03-.09

Original rule filed October 26, 1979; effective December 10, 1979. Amendment filed December 14, 1981; effective January 28, 1982. Repeal filed May 3, 1995; effective July 17, 1995. New rule filed January 7, 1997; effective March 23, 1997. Repeal and new rule filed June 18, 2002; effective September 1, 2002. Amendment filed October 11, 2004; effective December 25, 2004. Amendment filed January 14, 2005; effective March 30, 2005. Amendment filed February 15, 2006; effective May 1, 2006. Amendment filed March 14, 2006; effective May 28, 2006.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-29-105, and 68-29-125.