Summary:
Summary Statement of Deficiencies 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 an interview with the Histopathology Processor, the laboratory failed to follow written policies and procedures to assess and document the competency of the Technical Supervisor based on the responsibilities of the position. All patients tested at this lab have the potential to be affected. Findings Include: 1. Review of the laboratory's "Mohs Laboratory Manual," on 5/15/18, found a policy and procedure entitled "Competency Evaluation of Technical Supervisor.," which complied with regulations. 2. The Surveyor requested the competency assessment for the Technical Supervisor for the year 2017-2018. The Histopathology Processor confirmed, on 5/15/18 at 9:21 am, that the competency assessment for the Technical Supervisor was not performed in 2017 or 2018, thus, the documents could not be produced. 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 --