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 General Supervisor (GS), the laboratory failed to assess competency for 1 (Testing Personnel #2) of 2 testing personnel listed on the CMS-209 form. Findings include: 1. A review of the laboratory's testing personnel competency assessments revealed a lack of competency assessment for Testing Personnel #2 performing histopathology testing in 2019. 2. An interview on 8/31/21 at 11:56 am with the GS confirmed the laboratory did not have documentation of Testing Personnel #2's histopathology competency in 2019. 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 --