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 and interview with the Practice Manager, the laboratory failed to follow its competency assessment policy for 1 (Testing Personnel #1) of 8 testing personnel listed on Form CMS-209. Findings include: 1. A review of the laboratory's "Personnel Competency Testing" revealed a section stating, "The competency testing and assessment can be reviewed by another Forefront physician, nurse practitioner or physician assistant." 2. A review of the laboratory's personnel competency assessments revealed Testing Personnel #1 had assessed their own competency assessments on 9/28/23 and 3/29/23. 3. An interview on 11/7/23 at 11:20 am with the Practice Manager confirmed Testing Personnel #1 had performed their own competency assessments and had not had assessments performed by other qualified laboratory staff. 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 --