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 review of laboratory quality assurance (QA) policy, laboratory personnel assessment record, and interview with the registered nurse (RN), the laboratory failed to monitor testing personnel (TP) competencies in 2018. Findings include: 1. The laboratory QA, the laboratory director signed on 05/01/2017, states "All testing personnel will be monitored at least annually to assure they are competent ..." 2. The 01/2018 laboratory personnel assessment record review concludes as follows: TP Throat Culture #2 No annual competency assessment #3 No annual competency assessment #4 No annual competency assessment 3. Of these TP, none (3 of 3) had any annual competency assessments (throat culture) in January 2018. 4. The laboratory had no other 2018 competency monitoring records. 5. The RN confirmed above findings on 09/12/2018 at 10:00 AM. ====================================== 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 --