Summary:
Summary Statement of Deficiencies D6053 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 semiannually during the first year the individual tests patient specimens. This STANDARD is not met as evidenced by: Based on review of the laboratory's competency assessment records and interview with the regional clinic manager, the technical consultant (TC) failed to evaluate and document the performance of 4 of 5 testing personnel (TP) responsible for performing potassium hydroxide (KOH) and wet mount examinations for their semi-annual competency from 03/01/2022 to the day of survey. Findings include: 1. On the day of survey, 02/27/2023 at 01:01 pm, the laboratory was unable to produce the onsite semi- annual competency assessment records for 4 of 5 TP (CMS 209 personnel #2, #3, #4, and #5) that performed mycology (KOH) and parasitology (wet mounts) slide examinations from 03/01/2022 to 02/27/2022. 2. The laboratory performed 29 mycology/parasitology tests in 2022 (annual volume listed on CMS 116). 3. The regional clinical manager confirmed the finding above on 02/27/2023 around 02:00 pm. 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 --