Farmington Correctional Center

Summary Statement of Deficiencies D6018 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(iii) The laboratory director is responsible for the overall operation and administration of the laboratory, including the employment of personnel who are competent to perform test procedures, and record and report test results promptly, accurate, and proficiently and for assuring compliance with the applicable regulations. (e) The laboratory director must-- (e)(4)(iii) Ensure that all proficiency testing reports received are reviewed by the appropriate staff to evaluate the laboratory's performance and to identify any problems that require

Summary Statement of Deficiencies D6054 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(9) The technical consultant is responsible for evaluating and documenting the performance of individuals responsible for moderate complexity testing at least annually, after the first year. This STANDARD is not met as evidenced by: Based on review of personnel records, the laboratory's individualized quality control plan (IQCP), personnel roster (CMS form 209) and interview with technical consultant #1, two of two individuals serving as technical consultants failed to evaluate and document the performance for eighteen of eighteen testing personnel performing moderate complexity troponin testing for 2017 and to date November 27, 2018. Findings: 1. Review of personnel records revealed the laboratory did not have documentation to show eighteen testing personnel received competency/performance evaluations for 2017 and to date November 27, 2018. 2. The IQCP states, "All personnel trained to perform the troponin test must complete a test every twelve months- semiannually during the first year that the person tests samples and annually thereafter. This competency test should be conducted by the technical consultant." 3. Review of the CMS laboratory personnel roster (form 209) showed two individuals listed as technical consultants. 4. Interview with technical consultant #1 on November 27, 2018 at 11:00 AM confirmed, individuals serving as technical consultants failed to evaluate and document the competency of testing personnel performing moderate complexity troponin testing at least annually and follow the IQCP. 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 --