Summary:
Summary Statement of Deficiencies D6120 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(7)(8) (7) The technical supervisor is responsible for identifying training needs and assuring that each individual performing tests receives regular in-service training and education appropriate for the type and complexity of the laboratory services performed; (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 the review of the laboratory's CMS-209 Laboratory Personnel Report, lack of competency assessment documentation and interview with the Supervisor of Hospital Operations (SHO), the Technical Supervisor (TS) failed to perform the six month competency for one of one high complexity testing personnel (TP). Findings: 1. Review of the CMS-209 Laboratory Personnel Report found one individual listed as high complexity TP that had performed histopathology testing at this site for more than six months and was not listed on the 209 for the previous survey on 1/21/22. 2. The surveyor requested the six month competency for the one new TP. No six month competency was provided at the time of survey. 3. Interview with the SHO on 10/26 /23 at 9:15 a.m. confirmed, the TS failed to perform the six month competency for one of one high complexity TP. D6151 GENERAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1463(b)(3)(4) (3) The director or technical supervisor may delegate to the general supervisor the responsiblity for providing orientation to all testing personnel; and (4) Annually evaluating and documenting the performance of all testing personnel. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 2 -- This STANDARD is not met as evidenced by: Based on the review of the CMS 209 personnel form, general supervisor (GS) delegation form, lack of TP annual competency documentation and interview with the SHO, the GS failed to perform the annual competency assessment for five of five TP. Findings: 1. Review of the CMS209 personnel form revealed that five of six TP had performed high complexity testing for more than one year. 2. Review of the "GENERAL SUPERVISOR DELGATION FORM" revealed the GS had been delegated: "Annually evaluating and documenting the performance of all testing personnel." 3. Request was made for the annual competencies for five of five TP. The documents provided titled "PROFESSIONAL COMPETENCY ASSESSMENT" did not contain the 6 required elements for TP competency assessment for five of five TP for 2022 or to date of survey 2023. 4. Interview with the SHO on 10/26/23 at 9:15 a. m. confirmed, the GS failed to perform the annual competency assessment for five of five TP. -- 2 of 2 --