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 record review, patient testing review, and interview with the office manager, the laboratory failed to evaluate two [Testing Personnel #1 (TP1) and #4 (TP4)] of four testing personnel performing moderately complex testing at least annually from May 2017 to May 2019. Findings include: 1. A record review of the competency evaluations showed a lack of documentation of employee evaluations for TP1 and TP4 performing Tissue Examination for Fungi for two (May 2017 to May 2019) of two years. 2. A review of 41 patients having Tissue Examination for Fungi testing during the period between 10/6/17 and 4/24/19 revealed one patient (#983831) had testing performed by TP1. 3. During the interview on 5/22/19 at 9:07 am, the office manager confirmed competency evaluations of Tissue Examination for Fungi were not available for TP1 and TP4. 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 --