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 record review and interview with testing person (TP) #1, the laboratory director (LD) acting as the technical supervisor (TS) failed to perform and document the competency reviews on all TP to assure that the staff maintain their competency to perform test procedures and report test results promptly, accurately, and proficiently. Findings: 1. The laboratory currently has 2 TP listed on the "Laboratory Personnel Report (CLIA)" (CMS-209) who perform grossing of patient tissue specimens which are received in the laboratory for histopathology testing. 2. A review of competency assessment records from 2021 through 2023 showed that there was no documentation that the LD/TS performed a competency assessment on TP #1 in 2022. 3. During an interview on 09/11/2023 at 11:10 AM, TP #1 confirmed that the LD/TS did not perform a competency assessment on them in 2022. 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 --