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 review of the laboratory competency assessment records and interview with the Technical Supervisor (TS), the TS failed to evaluate the competency assessment of 3 of 3 Testing Personnel (TP) who performed Microbiology examinations in 2021 and 2022. Findings include: 1. On the day of survey 12/05/2022 at 02:32 pm, the TS could not provide competency assessment records performed by the TS for 3 of 3 TP for the following testing in 2021 and 2022: - 2021: TP#2 (CMS 209 personnel #6): Gram Stain Evaluation of vaginal Smears by Nuget Criteria. TP#4 (CMS 209 personnel #7): Gram Stain Evaluation of vaginal Smears by Nuget Criteria. - 2022: TP #1(CMS 209 personnel #5): Identification of Group B Streptococcus TP#2 (CMS 209 personnel #6): Gram Stain Evaluation of vaginal Smears by Nuget Criteria. TP#4 (CMS 209 personnel #7): Gram Stain Evaluation of vaginal Smears by Nuget Criteria and Identification of Group B Streptococcus. 2. The TS confirmed the findings above on 12/06/2022 at 05:15 pm. 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 --