Summary:
Summary Statement of Deficiencies D0000 An announced CLIA Recertification survey was conducted at the Carilion Clinic Family Medicine-Christiansburg on August 11, 2021 by the Virginia Department of Health's Office of Licensure and Certification. The laboratory was surveyed under 42 CFR part 493 CLIA Requirements. Specific deficiencies cited are as follows: 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 policy and procedures (P&P), lack of documentation, and interview, the laboratory did not have a P&P for performing competency assessments on testing personnel at the date of the survey on 08/11/21. Findings include: 1. Review of the available P&P's revealed lack of documentation of a policy for performing competency assessments on testing personnel performing patient testing. 2. During an exit interview with the primary testing personnel and technical consultant on 08/11/21 at approximately 12:15 PM, the documentation was not available for review and the above-specified finding confirmed. 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 --