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, the laboratory failed to perform competency evaluations on the clinical consultant and technical supervisor from 1/15/17 to 1/15 /19. Findings: Review of the laboratory employee competencies revealed no competencies were performed on the clinical consultants and technical supervisors. During an interview on 1/15/19 at 9:53 AM, Technical Supervisor acknowledged that there were no competencies performed on the clinical consultant and technical supervisor. Based on review of employee competencies and interview with the Office Manager, the laboratory failed to perform competency evaluations on 6 (#A-E and G) clinical consultants and technical supervisors out of 7 (#A-G) listed on the CMS 209 for 2 of 2 (2013-2015) years reviewed. Findings Included: Review of the employee competencies revealed no competencies performed on 6 clinical consultants and technical supervisors. During an interview on 11/05/15 at approximately 10:00 a.m., the Office Manager confirmed that there were no competencies performed on the clinical consultants or technical supervisors. 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 --