Summary:
Summary Statement of Deficiencies D6054 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(9) The technical consultant is responsible for evaluating and documenting the performance of individuals responsible for moderate complexity testing at least annually, after the first year. This STANDARD is not met as evidenced by: Based on a review of the Centers for Medicare and Medicaid Services (CMS) 209 form, review of personnel records, and staff interview, the technical consultant failed to perform annual competency assessments for five of five providers who read urine cultures in 2023. The findings include: 1. A review of the CMS-209 form revealed fourteen testing personnel who perform moderately complex patient testing. 2. A review of the personnel records revealed no documentation of annual testing personnel (TP) competency assessments for providers who read urine cultures (TP1, TP11, TP12, TP13, and TP14) in 2023. 3. An interview with the Nurse Manager on 10.03.2024 at 12:15 p.m. confirmed the above survey 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 --