Summary:
Summary Statement of Deficiencies 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 personnel record review, quality assurance record review, and interview with laboratory personnel, the technical supervisor did not document a competency evaluation for one of one testing person annually. Findings include: When the surveyor reviewed of personnel records on 07/10/18, there was no documentation to indicate that the Mohs surgeon who read slides had a competency evaluation over the past year. During an interview with the Laboratory Manager at 10:40 a.m. on 07/10 /18, she said that she had missed making sure that it was done this year. The "Bi- annual Laboratory Self Inspection Checklist" indicated that Mohs surgeons not serving as the lab director must have an annual competency signed by the corresponding lab director for each location. 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 --