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 a review of the PPM (Provider Performed Microscopy) Testing Personnel listed on the "CMS Form 209- Laboratory Personnel Report" performing KOH (Potassium Hydroxide) and Wet Prep analysis and an interview with the Technical Consultant, determined the laboratory failed to establish a procedure to assess PPM competencies for Providers performing KOH and Wet Prep analysis testing for 2019. The findings include: 1. A review of the five PPM testing personnel listed on the CMS Form 209 did not have competencies documented for 2019 for performing KOH and Wet Prep analyis. 2. An interview with the Technical Consultant at approximately 2:00 p.m. on February 13, 2020 confirmed there was no procedure established for assessing PPM competencies. =================================== 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 --