Dennis S Gray, Md, Psc

CLIA Laboratory Citation Details

1
Total Citation
2
Total Deficiencyies
1
Unique D-Tag
CMS Certification Number 18D0907834
Address 1169 Eastern Parkway Suite 1111, Louisville, KY, 40217
City Louisville
State KY
Zip Code40217
Phone(502) 456-4100

Citation History (1 survey)

Survey - July 27, 2018

Survey Type: Standard

Survey Event ID: DQ1Z11

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, the Technical Consultant failed to perform and document annual competency using the six (6) mandated competency assessment requirements for testing personnel. Competency assessment was performed using zero (0) of six (6) methods of assessment for two (2) out of two (2) employees from July 19, 2016 through July 26, 2018. Findings include: Record review on 07/27/2018 revealed there was no documented competency assessments between July 19, 2016, and July 26, 2018, for two (2) employees that included the following: competency assessments failed to include 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 maintence records, assessment of testing external proficiency testing samples and problem solving skills. An interview with the staff on 07/27/2018 at 10: 28 AM revealed the facility failed to have a system in place between July 19, 2016, and July 26, 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 --

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