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 Technical Supervisor failed to evaluate the competency of 1 of 3 testing personnel as described by procedure. Findings are as follows: 1. The laboratory performed Mohs Micrographic Dermatopathology testing as confirmed by the Laboratory Director (LD) during a tour of the laboratory on 3/1/18 at 10:05 a.m.. 2. Requirements to perform reviews of 3 cases per quarter of each year for each authorized Mohs Testing Personnel were established in the Mohs Slide Interpretation Quality Assessment Plan procedure located in the Mohs Lab Procedures and Forms Manual. 3. Competency assessment records for Testing Personnel 10 (TP10) during Quarter #1, 2017 were not found during review of laboratory documents located in the Mohs Quality Assurance Physician Slides binder. 4. The laboratory was unable to provide the missing competency assessment records upon request. 5. In an interview on 3/1/18 at 12:45 p. m., the LD confirmed the above finding. 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 --