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 with risk manager, technical supervisor failed to assess the annual competency evaluation of dermatologist-MOHS surgeon (1 out of 3 testing personnel), from December 2016 to December 7, 2018. The findings include: Competency record review on December 7, 2018 at 1:30pm for 2-year period (12 /2016-12/7/2018) showed 1- The annual competency assessment review for two histology-staining technicians (testing person #1 and#2). 2- No annual competency assessment review for the dermatologist-MOHS surgeon (testing person #3) for histopathology subspecialty laboratory. During an interview on December 7, 2018 at 2: 00 PM, risk manager confirmed that the technical supervisor did not perform an annual competency assessment review- evaluation for the dermatologist-MOHS surgeon (testing person #3) for histopathology subspecialty laboratory from 12/2016 to 12/7/18. 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 --