Summary:
Summary Statement of Deficiencies D6046 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(8) (b) The technical consultant is responsible for-- (b)(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 staff interview and record review on October 18, 2018, the Technical Consultant failed to perform and document annual competency using the 6 mandated competency assessment requirements for testing personel. Competency assessment was performed using one (0) of six (6) methods of assessment for nine (9) out of nine (9) employees from October 20, 2016 through October 17, 2018. Findings include: Record review on October 18 revealed there was no documented competency assessments between October 20, 2016 and October 17, 2018, for nine (9) employees that included the folowing: competency assessments failed to include direct observation of routine patient test performance, direct observation of performance of instrument maintenance function checks and calibration, monitoring the recording and reporting of test results, review of worksheets, review of quality control records, review of proficiency test results, review of maintence records, assessment of testing external proficiency testing samples and problem solving skills. An interview with the staff on October 18, 2018 at 10:02 AM revealed the facility failed to have a system in place between October 20, 2016 and October 17, 2018 to ensure competency was performed using all six (6) mandated competency assessment requirements from October 20, 2016 and October 17, 2018. 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 --