Summary:
Summary Statement of Deficiencies D0000 Complaint Intake KY00039353. A focused complaint survey conducted on 06/13 /2023 through 06/14/2023 found Kings Daughters Medical Center's laboratory in compliance with 42 CFR Par 493, Requirements for Laboratories with one standard level deficiency cited. 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 immunohematology competency records and an interview with the General Supervisor, the Technical Supervisor failed to evaluate and document the semiannual competency for one (1) of one (1) [sampling] Testing Personnel during the first year of patient testing. Findings included: a. A review of immunohematology competency records revealed one Testing Person began immunohematology testing in June 2022. Further review of the competency records revealed one (1) semiannual competency performed by Testing Personnel #15 (as stated on the Centers for Medicare and Medicaid 209 form) and the General Supervisor. b. An interview of the Blood Bank General Supervisor on 6/14/2023 at 9:00am in the conference room confirmed these findings. 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 --