Remedial Action Plan

DOE-STD-1112-98

5.8

Remedial Action Plan

If a service laboratory does not pass the criteria for all the analytes for which it has applied in a given

matrix, but does pass the criteria for some analytes, the service laboratory (in conjunction with the

DOE Contractor if a commercial laboratory) shall prepare a remedial action plan to implement

immediately. The plan is sent through the DOE field office to the HQ DOELAP Administrator with

a copy to the Performance Evaluation Program Administrator. When more than one procedure or

counting system is used to meet the special needs at a facility, it is possible for a procedure or

counting system to receive final accreditation while other procedures or counting systems require a

remedial action plan. If the service laboratory has demonstrated satisfactory performance in a

radiobioassay matrix or category for a particular analyte, and if the remedial action plan is initiated,

the accreditation process may continue for those analytes. Approval of partial accreditation shall

only be granted with the successful completion of the on-site assessment, the approval of the

Oversight Board, and the concurrence of the HQ DOELAP Administrator.

The DOE Contractor or service laboratory shall submit a written plan for resolving identified

concerns and deficiencies to the cognizant field office for approval within 30 days of receipt of the

assessment report. The approved plan shall be forwarded by the field office to the Performance

Evaluation Program Administrator, with a copy to the HQ DOELAP Administrator, within 45 days

of receipt of the assessment report.

Deficiencies identified during the initial site assessment may require some time to correct. These

corrections shall be complete before accreditation is granted. Deficiencies noted during subsequent

triennial site assessments of an accredited service laboratory should be corrected within 90 days of

the close-out meeting. When an out-of-calibration apparatus is cited, the apparatus shall not be used

for DOELAP accredited work until corrective action has been completed.

The contractor or field office may appeal an assessment finding to the DOELAP Appeals Board at

any point in the accreditation process (DOE-STD-1111-98).