Summary:
Summary Statement of Deficiencies D6127 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(9) The technical supervisor is responsible for evaluating and documenting the performance of individuals responsible for high 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 personnel records, and staff interview, it was revealed the laboratory failed to have documentation of the technical supervisor evaluating the competency of 1 of 1 testing persons twice within the first year of grossing histology specimens. The findings include: 1. A review of the laboratory's personnel records for testing personnel number 2 (as listed on Form CMS 209) identified she started performing the grossing of histology specimens in April 2022. Thus, two competency assessments were required by April 2023. 2. The laboratory was asked to provide documentation of two competency assessments being performing on testing personnel number 2 within her first year of testing. No documentation was provided. 3. The laboratory director confirmed the findings in an interview in her office on 12/13/2023 at 0930 hours. 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 --