Summary:
Summary Statement of Deficiencies D0000 At the time of the announced, onsite recertification survey, Baptist Primary Care Inc was found to not be in compliance with the CLIA laboratory requirements of 42 CFR 493. 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 record review and staff interview, the laboratory failed to perform annual competency assessments for 2 out of 2 Testing Personnel (#A, #B) for one out of two years reviewed (2023 - 2024). The findings include: Review of the CMS 209, Laboratory Personnel Report, signed by the Laboratory Director on 4/26/24 showed there were two Testing Personnel (TP). Review of staff competency records showed TP #A had competency assessment performed in December 2022 and February 2024. TP #B had competency assessment performed December 2022 and January 2024. During the interview on 5/1/24 at 2:15pm, TP #A confirmed competency assessments had not been completed annually. 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 --