CLIA CoW - Laboratory Director

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Our health system owns approximately 30 physician practices.  The offices have worked together to standardize their waived Laboratory testing menu and would love to have an online policy/procedure document control. Ideal state would be to have one Laboratory director sign the policies online.


I know each office must have their own CoW, but I cannot find documentation where it cannot be the same Lab director on each Certificate of Waiver. ( I do know the Lab director on a PPM cannot direct more than 5 labs)


Any insight??

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WE have our clinics  are  standardized.  They all have different directors but I prepare the policies and procedures.


They all follow the same policies and procedures, whether waived or PPM. 


The only difference is the PPM gets Proficiency policy, procedure and subscription.


They all have to do orientation, training on procedures how to use the forms to report QC and patients. Competency certification is every year in the summer.


All the paper forms we use, even though they have a computer system ( separate  from the hospital)  are the same.


I sign those forms monthly when I go around and do my QI visits.


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Paulette Sivak
over 8 years ago
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