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 record review and interview, the technical supervisor failed to evaluate one (#4) of three testing personnel performing highly complex histopathology Mohs' inking at least annually. Findings include: 1. On December 17, 2018 at 10:12 AM, record review of the competency evaluations revealed there was no documentation to show the histopathology Mohs' evaluation had been performed and documented in 2017 for testing personnel #4. 2. During the interview on December 17, 2018 at 10:12 AM, testing personnel #2 as listed on the CMS-209 confirmed there was no documentation of the annual review in 2017. 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 --