On-time Inspections Returning to the CAP

Communication Date: June 29, 2022
NOTE: The information below was current at the time of communication. Subsequent CAP changes, if applicable, are not reflected in this eAlert.

On-time laboratory inspections are critical for maintaining an environment of continuous compliance and quality improvement to ensure the laboratory is providing the highest level of quality service for the patients you serve. As a CMS-approved accreditation organization under CLIA, the CAP is required to have an inspection process that inspects laboratories biennially.

As the world continues to move past the challenges of COVID-19, the CAP is returning to the practice of completing inspections within the 90-day inspection window.

Whether your inspection is scheduled, overdue, or in the future, we need your cooperation for completing the laboratory inspection. For laboratories anticipating an inspection team assignment, we are actively working to fulfill this assignment. The following steps ensure an expeditious process.

On-time Inspections

• The inspection team to select a date in the 90-day inspection window.
  • Inspections will not occur on the established blackout dates selected by the laboratory or on CAP holidays.
• The inspection team to notify the CAP and the laboratory concurrently of the scheduled inspection date(s) prior to inspection.

• Laboratories to pre-determine delegation of inspection responsibilities in case an individual is unavailable on the day of inspection.

• Laboratories to notify LAPAssignments@cap.org if a software or system upgrade will occur during their inspection window. To accomplish an on-time inspection, the inspection team will incorporate this change into the inspection plan.

• Laboratories to indicate to the inspection team if they are experiencing staffing shortages. The inspection team may send fewer inspectors or include shorter days of inspection to help reduce the impact on the laboratory. Some advance document review may be incorporated into the process if beneficial to the laboratory and the team.

Overdue Inspections

• The laboratory to provide blackout dates to the inspection team and the CAP within one week from receiving the scheduling email from the CAP.
  • A maximum of eight blackout dates in sets of at least two consecutive days may be selected within the 90-day period.
  • Inspections will not occur on the established blackout dates selected by the laboratory or on CAP holidays.
• The inspection team to select an inspection date to occur within 30–90 days of receiving the scheduling email from the CAP and blackout dates from the laboratory. It is critical to complete the inspection without further delay.

• The inspection team to notify the CAP and the laboratory concurrently of the scheduled inspection date(s) prior to inspection.
• Laboratories to pre-determine delegation of inspection responsibilities in case an individual is unavailable on the day of inspection.

• Laboratories to notify LAPAssignments@cap.org if a software or system upgrade will occur during their inspection. To accomplish the inspection, the inspection team will incorporate this change into the inspection plan.
• Laboratories to indicate to the inspection team if they are experiencing staffing shortages. The inspection team may send fewer inspectors or include shorter days of inspection to help reduce the impact on the laboratory. Some advance document review may be incorporated into the process if beneficial to the laboratory and the team.

Virtual Inspections

For laboratories unable to host inspection teams in person, supporting technology platforms allow us to effectively work in a digital environment, including virtual inspections. This capability facilitates on-time inspections.

Questions? Call an accreditation representative at 800-323-4040, +001-847-832-7000 option 1, or email accred@cap.org.