Advanced Pain Medicine

Summary Statement of Deficiencies D5209 PERSONNEL COMPETENCY ASSESSMENT POLICIES CFR(s): 493.1235 As specified in the personnel requirements in subpart M, the laboratory must establish and follow written policies and procedures to assess employee and, if applicable, consultant competency. This STANDARD is not met as evidenced by: Based on review of competency assessment records and interview with general supervisor (GS)#2, the laboratory failed to perform a competency assessment for 2 of 2 clinical consultants (CC) for their supervisory responsibilities by a qualified personnel in 2022. Finding Include: 1. On the day of the survey,03/21/2023 at 12:22 pm. review of the competency assesment records revealed that the competency assessment for 2 of 2 CC (CMS 209 personnel #4 and #5) was performed by a personnel that was not qualified in 2022. 2. The highest degree for the personnel that performed the competency assessment for the CC was a bachelors degree in medical technology. 3. GS#2 confirmed the findings above on 03/21/2023 at 2:30 pm. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 1 --

Summary Statement of Deficiencies D5403 PROCEDURE MANUAL CFR(s): 493.1251(b) The procedure manual must include the following when applicable to the test procedure: (1) Requirements for patient preparation; specimen collection, labeling, storage, preservation, transportation, processing, and referral; and criteria for specimen acceptability and rejection as described in 493.1242. (2) 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 used in testing. (5) Calibration and calibration verification procedures. (6) The reportable range for test results for the test system as established or verified in 493.1253. (7) Control procedures. (8)