Colorectal Surgical & Gastroenterology

CLIA Laboratory Citation Details

1
Total Citation
2
Total Deficiencyies
1
Unique D-Tag
CMS Certification Number 18D0903152
Address 2620 Wilhite Dr, Suite 205, Lexington, KY, 40503
City Lexington
State KY
Zip Code40503
Phone859 278-0185
Lab DirectorHENRY HARLAMERT

Citation History (1 survey)

Survey - June 20, 2018

Survey Type: Standard

Survey Event ID: WTJ811

Deficiency Tags: D6046 D6046

Summary:

Summary Statement of Deficiencies D6046 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(8) (b) The technical consultant is responsible for-- (b)(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 staff interview and record review, it was determined the Technical Consultant failed to perform and document annual competency using the six (6) mandated competency assessment requirements for testing personal. Competency assessment was performed using zero (0) of six (6) methods of assessment for two (2) out of two (2) employees from June 10, 2016 through June 19, 2018. Findings include: Record review on 6/20/18, revealed there was no documented competency assessments between June 10,2016 and June 19, 2018, for two (2) employees to include the following: direct observation of routine patient test performance; direct observation of performance of instrument maintenance function checks and calibration; monitoring the recording and reporting of test results; review of worksheets; review of quality control records; review of proficiency test results; review of maintenance records; assessment of testing external proficiency testing samples and problem solving skills. Interview with the staff on 6/20/18 at 09:57 AM, revealed the facility failed to have a system in place between June 10, 2016 and June 19,2018, to ensure competency was performed using all six (6) mandated competency assessment requirements. 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 --

πŸ”’ Unlock Deficiency Summary

Get full access to the detailed deficiency summary for this facility

One-time payment β€’ Lifetime access