Summary:
Summary Statement of Deficiencies D6120 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(7)(8) (7) The technical supervisor is responsible for identifying training needs and assuring that each individual performing tests receives regular in-service training and education appropriate for the type and complexity of the laboratory services performed; (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 review of testing personnel (TP) competency records and discussion with two TP present during survey, the Technical Supervisor (TS) failed to ensure competency assessments were completed annually for the two (2) Histotechnicians (HT's) performing grossing. Findings include: 1. Upon review of laboratory competency records and interview with the two (2) HT's on site (HT1 and HT2) at approximately 2:00 pm 05/10/2023 confirmed that no competency assessment of their grossing abilities had been performed since the last survey performed 04/21/2021. 2. Lack of evidence of competency assessment during survey revealed that the TS failed to ensure that competency assessment for grossing of anatomicasl specimens removed from human patients by biopsy was conducted annually for TP performing anatomical grossing. 3. The laboratory reports performing 11,789 histopathology slide preparations for the past year. 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 --