Summary:
Summary Statement of Deficiencies D0000 A recertification survey for compliance with 42 CFR Part 493, Requirements for Laboratories, was conducted on 2/12/19. The De Smet Community Health Center laboratory was found not in compliance with the following requirement: D6052. D6052 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(8)(vi) The procedures for evaluation of the competency of the staff must include, but are not limited to assessment of problem solving skills. This STANDARD is not met as evidenced by: Based on review of personnel competency records, quality assurance (QA) records, and interview with laboratory staff A, the technical supervisor failed to ensure annual competency assessments included assessment of problem solving skills for two of two laboratory staff (B and C). Findings include: 1. Review of the annual competency assessments for the staff identified above revealed: *Laboratory staff B's initial (dated 8/3/18) and annual (dated 2/4/19) competency assessments had been completed and signed by laboratory staff A and the laboratory director. a. The competency assessment forms did include the assessment of problem solving skills related to the performance of laboratory testing. b. The line designated for assessment of problem solving skills had been left blank on both assessments. *Laboratory staff C's initial (dated 6/14/18) and annual (dated 2/4/19) competency assessments had been completed and signed by laboratory staff A and the laboratory director. a. The competency assessment forms did include the assessment of problem solving skills related to the performance of laboratory testing. b. The line designated for assessment of problem solving skills had been left blank on both assessments. Review of the 2018 QA records dated 12/17/18 and signed by laboratory staff A and the laboratory director revealed personnel competency completed and acceptable. Interview with laboratory staff A on 2/12/18 at 8:35 a.m. revealed she was not aware the assessment process included assessment of problem solving skills. 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 --