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 document review and interview with laboratory personnel, the Histopathology Technical Supervisor failed to ensure 1 of 1 testing personnel received competency assessments for one of two test procedures performed by the laboratory in 2020 and 2021. Findings are as follows: 1. The laboratory performed Mohs Micrographic Surgery under the specialty of Histopathology as confirmed by the Histotechnician (HT) during a tour of the laboratory on 09/28/22 at 1:05 p.m. The HT indicated she performed tissue inking for the Mohs procedure. 2. The Responsibilities of Histotechnicians procedure found in the Mohs Lab Manual indicated the histotechnician was responsible for inking tissue obtained from the Mohs procedure. 3. A tissue inking competency assessment procedure was not found during review of laboratory policies and procedures. 4. Inking competency assessment documents for the HT were not found during review of 2020 and 2021 laboratory records. 5. The laboratory was unable to provide the missing documents upon request. 6. In an interview at 2:40 p.m. on 09/28/22, the HT confirmed the above 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 --