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 the review of personnel records and interview with the Laboratory Director on 7/20/23, the laboratory failed to perform and document competency assessments for 9 of 9 Testing Personnel (providers) who perform KOH (potassium hydroxide) prep, Tzanck prep and scabies microscopy during 2020, 2021, and 2022. Findings include: A review of personnel records revealed the absence of documentation of competency assessments for 9 of 9 providers who perform KOH prep, Tzanck prep and scabies microscopy. An interview with the Laboratory Director at approximately 11:10 a.m. confirmed that competency assessments are not performed and documented on providers who perform microscopy in the practice. 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 --