Northeast Arkansas Pain Medicine, Llc

Summary Statement of 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 upon a review of the CMS 209 form, review of laboratory documentation of competency assessment, lack of documentation and interview with laboratory staff, the laboratory failed to assess technical consultant competency on an annual basis for one of one technical consultant personnel listed on the CMS 209 form. Findings follow: A) Review of the CMS 209 form revealed that the technical consultant (number 2 on the form CMS 209) was employed by the laboratory. B) Review of competency assessment records revealed that the technical consultant (number 2 on the CMS 209 form) had records of competency evaluation in 2020, 2021, 2022, 2023 but no subsequent dates. C) Upon request, the laboratory was unable to provide competency assessments for technical consultant (number 2 on the CMS 209 form) for 2024 and 2025. D) In an interview on 7/23/26 at 08:50 a..m., the laboratory staff member (number 2 on the form CMS 209) confirmed that competency assessments for the technical consultant were not documented in 2024 and 2025 and the technical consultant had been contracted by the laboratory during those years. D5783

Summary Statement of Deficiencies D5783

Summary Statement of Deficiencies D5301 TEST REQUEST CFR(s): 493.1241(a) The laboratory must have a written or electronic request for patient testing from an authorized person. This STANDARD is not met as evidenced by: Through a review of laboratory policies and procedures, review of seven electronic medical records, lack of documentation, and interviews with laboratory personnel, it was determined the laboratory performed urine drug screens without a request from an authorized person. Survey findings include: A. A review of the laboratory policy and procedure manual revealed the following policy for test orders: The laboratory must perform test only at a written or electronic request from an authorized person (a physician). B. During a review of seven patient electronic medical records, the surveyor requested to see the physicians orders for the urine drug screens. During the review (11:21 on 11/19/2021) surveyor was told, by laboratory employee #3 (as listed on form CMS-209), that there are no orders for the patient drug screens, in the electronic medical records. C. In interview, at 11:21 a.m. on 11/19/2021, laboratory employee #3 stated that she performs drug screens on patients based on a protocol hand written on a sheet of paper from a note pad, which was posted on the wall in the laboratory. The hand written protocol was not signed by the physicians to indicate it was a standing order for patient laboratory testing. She further stated that a drug screen would be performed on any patient presenting in the waiting room with any behavior to suggest impairment. 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 --