Summary:
Summary Statement of Deficiencies D0000 An unannounced CLIA recertification survey was conducted at I Pathology on 06/13 /19. The laboratory is not in compliance with 42 CFR Part 493, Requirements for Laboratories. The following is a description of the standard level 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 CEO (Chief Executive Officer) the laboratory failed to perform competency evaluations on Testing Person #A for 2 out of 2 years (2017-2019). Findings Included: Review of employee records revealed that Testing Person #A was hired 11/17. There were no competencies performed on Testing Person #A. There was no policy that specified the competencies needed to be conducted at 6 months the first year and yearly thereafter. Interview on 06/13/19 at 1: 58 PM the CEO confirmed that no competency evaluations had been performed on Testing Person #A and that they did not have a policy to perform competency evaluations. 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 --