Summary:
Summary Statement of Deficiencies D6028 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(10) (e)(10) Employ a sufficient number of laboratory personnel with the appropriate education and either experience or training to provide appropriate consultation, properly supervise and accurately perform tests and report test results in accordance with the personnel responsibilities described in this subpart; This STANDARD is not met as evidenced by: Based on review of personnel credentials and interview with the technical consultant (TC), the laboratory director (LD) failed to ensure that testing personnel (TP) with degrees from foreign institutions had an evaluation of their credentials to determine United States equivalency prior to performing laboratory testing. Findings: 1. The Laboratory Personnel Report (CMS-209) lists four TP. 2. The degree for TP #3 was earned in a foreign country and there was no foreign credential equivalency evaluation present at the time of the survey. 2. During an interview on 03/05/2025 at 11:00 AM, the TC confirmed that the LD did not ensure that TP with degrees from foreign institutions had an evaluation of their credentials to determine United States equivalency prior to testing patient specimens. 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 --