Summary:
Summary Statement of Deficiencies D0000 The following deficiencies were cited as the result of a recertification survey on 03/11 /2021 for 42 CFR part 493 Laboratory Requirements. D6046 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(8) (b) The technical consultant is responsible for-- (b)(8) Evaluating the competency of all testing personnel and assuring that the staff maintain their competency to perform test procedures and report test results promptly, accurately and proficiently. This STANDARD is not met as evidenced by: Based on the review of personnel records, CMS (Centers for Medicare & Medicaid Services) Personnel Report Form 209, email and interview with the Technical Consultant, the Technical Consultant failed to perform competency evaluations for 1 Testing Person (TP#3) of 3 (TP#1-TP#3)Testing Personnel. Finding are: A. Review of the CMS Personnel Report Form 209, signed by the Laboratory Director on 03/09 /2021, indicated TP#1 was a current testing person at this laboratory, Lab A. B. Review of personnel records revealed no documentation of competency for TP#1 at this laboratory. Her personnel records indicated that she had worked for one of the sister laboratories, Lab C in 2018 and 2019. C. During interview on 03/11/2021 at 7: 50 am, the Technical Consultant stated the competency was done at Lab C. D. Review of an email dated 03/15/2021 from the Technical Consultant indicated TP#1 was hired on 03/12/2018 for the Lab C location and no indication she was transferred to this laboratory prior to the survey. D6066 TESTING PERSONNEL QUALIFICATIONS CFR(s): 493.1423(b)(4)(ii) Have documentation of training appropriate for the testing performed prior to analyzing patient specimens. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 2 -- This STANDARD is not met as evidenced by: Based on the review of personnel records, CMS (Centers for Medicare & Medicaid Services) Personnel Report Form 209 and email, there was no training documentation for 1 Testing Person (TP#3) of 3 (TP#1-TP#3)Testing Personnel. Finding are: A. Review of the CMS Personnel Report Form 209, signed by the Laboratory Director on 03/09/2021, indicated TP#3 was a current testing person at this laboratory, Lab A. B. Review of personnel records revealed no documentation of training for TP#3 at this laboratory. Her personnel records indicated that she had worked for one of the sister laboratories, Lab C in 2018 and 2019. C. Review of an email dated 03/15/2021 from the Technical Consultant indicated TP#3 was hired on 03/12/2018 for the Lab C location and no indication she was transferred to this laboratory prior to the survey. D9999 Laboratory Identifiers Atrisco Lab A Paradise Lab B Las Estancias Lab C Northside Lab D Santa Fe Lab E -- 2 of 2 --