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 a review of the personnel records and interviews with Testing Personnel #2, the Technical Supervisor failed to assure initial training was performed for an individual performing grossing. This was noted on one of two personnel records reviewed by the surveyor. The finding include: 1. A review of the personnel records revealed Testing Personnel #2 started grossing in July 2020. There was no documentation of initial training being performed. 2. During an interview conducted on 05/13/2021 at 10:28 AM, Testing Personnel #2 was unaware of training being documented before grossing was performed on patient testing. D6127 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(9) The technical supervisor is responsible for evaluating and documenting the performance of individuals responsible for high complexity testing at least semiannually during the first year the individual tests patient specimens. This STANDARD is not met as evidenced by: Based on a review of the personnel records and an interview with Testing Personnel Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 2 -- #2, the Technical Supervisor failed to evaluate and document the performance of individuals at least semiannually during the first year of patient testing. This was noted on two of two personnel records reviewed by the surveyor. The finding include: 1. A review of the personnel records revealed Testing Personnel #1 and #2 semiannual evaluations were not performed for Grossing. Testing Personnel #1's initial training was documented 03/12/2020 and annual evaluation on 12/20/2020. Testing Personnel #2 was trained in July 2020, but no evidence of initial training and annual evaluation was documented on 12/20/2020. 2. During an interview conducted on 05/13/2021 at 10:30 AM, Testing Personnel #2 was not aware of semiannual evaluations being performed for Testing Personnel #1 and #2. -- 2 of 2 --