Summary:
Summary Statement of Deficiencies D0000 The Regional Manager was at the entrance conference conducted 02/18/2020. The survey process was discussed. An opportunity for questions and comments was given. The exit conference was held with the Regional Manager and QA Coordinator on 02 /18/2020. The laboratory was found to be in substantial compliance for the specialties /subspecialties for which it was surveyed. The standard level deficiencies cited were discussed. The process for submitting the corrections was explained. CMS form 2567 will be emailed from the Texas Health and Human Services Commission, Health Facility Compliance Arlington Group. D6128 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(9) The technical supervisor is responsible for evaluating and documenting the performance of individuals responsible for high complexity testing at least annually after the first year, unless test methodology or instrumentation changes, in which case, prior to reporting patient test results, the individual's performance must be reevaluated to include the use of the new test methodology or instrumentation. This STANDARD is not met as evidenced by: Based on review of Centers for Medicare and Medicaid Services (CMS) 209 form, personnel records, and interview with staff, the Technical Supervisor (TS) failed to perform the annual competency evaluations for 2 of 4 testing persons (TP-1, TP-2) performing high complexity testing in the specialty of histopathology in 2018. Findings: 1. Review of the CMS 209 form revealed TP-1 and TP-2 were listed as testing persons performing high complexity testing. 2. Review of personnel records revealed in 2018 the technical supervisor failed to perform annual competency evaluations for TP-1 and TP-2. 3. During an interview on 02/18/2020 at 11:17 am, the regional manager and QA coordinator confirmed the above findings. 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 --