Summary:
Summary Statement of Deficiencies D0000 An on-site validation survey was conducted on April 08, 2026 with the following standard level deficiencies cited. 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 the laboratory's policies and procedures, personnel records, competency assessment documentation and interview with Testing Personnel (TP) #2, according to the Centers for Medicare and Medicaid Services Form 209, the laboratory failed to establish and follow a policy for consultant competency assessment for 3 of 3 Technical Consultants (TCs). Findings Included: 1) Review of the laboratory's policy titled 'Baptist Health Annual and Initial Competency