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 review of employee competencies and interview with the General Supervisor C, the laboratory failed to perform competency evaluations on 1 (B) of 3 Clinical Consultants, 1 (B) of 3 Technical Supervisors, and 1 (F) of 6 General Supervisors listed on the CMS 209 for 2 of 2 (2017-2018) years reviewed. Findings Included: Review of the Form CMS 209, Laboratory Personnel Report, revealed Employee B was a Clinical Consultant and Technical Supervisor and Employee F was a General Supervisor. A review of the personnel files and employee competencies revealed no competencies had been performed for Employee B and F. Interview on 08 /14/18 at approximately 11:00 AM with General Supervisor C confirmed that there were no competencies performed for Employee B (Clinical Consultant and Technical Supervisor) and Employee F (General Supervisor). 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 --