Summary:
Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at The Neuropain Center on January 23, 2020. The laboratory is not in compliance with 42 CFR Part 493, Requirements for Laboratories. The following is a description of the standard level deficiencies: D5209 PERSONNEL COMPETENCY ASSESSMENT POLICIES CFR(s): 493.1235 As specified in the personnel requirements in subpart M, the laboratory must establish and follow written policies and procedures to assess employee and, if applicable, consultant competency. This STANDARD is not met as evidenced by: Based on record review and interview with the supervisor, the laboratory failed to perform competency evaluations on 2 out of 3 clinical consultants for 2 of 2 years (2018-2019) reviewed. Findings Included: Review of the CMS 209 revealed 3 clinical consultants. Review of the documents revealed no competency evaluations for 2 of 3 clinical consultants from January 2018 through December 2019. During the interview on 1/23/20 at 10:45 AM , the laboratory supervisor confirmed that there was no documented competency evaluations for clinical consultants # 4 and # 5. 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 --