Summary:
Summary Statement of Deficiencies D6046 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(8) (b) The technical consultant is responsible for-- (b)(8) Evaluating the competency of all testing personnel and assuring that the staff maintain their competency to perform test procedures and report test results promptly, accurately and proficiently. This STANDARD is not met as evidenced by: Based on review of laboratory personnel report (CMS-209), review of testing personnel (TP) competency records, review of laboratory personnel records and interview with TP #3 (laboratory manager -supervisor I) 6/2/21, the technical consultant (laboratory director) failed to evaluate the competency of 3 of 3 TP in 2019 and 2020. Findings: Review of CMS-209 submitted at time of survey revealed the laboratory director (LD) serves as the technical consultant (TC) for the laboratory. Review of 2019 and 2020 TP competency records revealed TP #3 performed the competency assessments of TP #1 and TP #2. They also revealed no competency assessments were performed for TP #3 in 2019 and 2020. Review of personnel records revealed TP #3 has an associates degree in medical technology and does not meet TC qualifications to perform TP competency assessments. Interview with TP #3 at approximately 1:00 p.m. confirmed she performed the competency assessments of TP #1 and TP #2. She stated she has been performing TP competency assessments for over 10 years at all of their locations and she also stated they had been previously inspected by an accrediting agency but were never told that she could not perform them because she did not meet TC qualifications. She also confirmed her (TP#3) competency was not performed. She stated she only performs testing occasionally at this facility. 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 --