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 upon review of records and interview with testing personnel (TP), the laboratory failed to ensure TP receive annual competencies on moderately complex hematology testing. Findings include: 1. There was no written documentation that could be produced for the sole person performing coagulation studies on patients for 2018 or 2019. These competencies were due in March of each year. 2. During an interview with TP on 4/23/2019 at approximately 1130 a.m., she confirmed that there had been no annual competency performed for either year. 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 --