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 the laboratory's competency assessment records and interview with the Laboratory Director (LD) (CMS 209), the laboratory failed to establish a procedure to assess the competency of 6 of 7 Clinical Consultants (CC) (CMS 209) for their consulting responsibilities in Tissue Pathology in 2022 and 2023. Findings include: 1. On the day of survey, 10/06/2023 at 10:10 AM, the laboratory could not provide competency assessment records for the following personnel for their consulting responsibilities in 2022 and 2023: -6 of 7 CC (CMS 209 Personnel #2, #3, #4, #5, #6, #7) 2. The LD confirmed the findings above on 10/06/2023 at 10:48 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 --