Summary:
Summary Statement of Deficiencies D0000 At the time of the announced, onsite recertification survey, Northeast Florida State Hospital was found to NOT be in compliance with the CLIA laboratory requirements of 42 CFR 493. . 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 staff interview, the laboratory failed to document annual competency assessment for three (Testing Person A, B, & C) of three testing personnel for two of two years reviewed (2018-2019). Findings include: The laboratory was unable to provide documentation of annual competency assessment at time of survey. The competency assessment provided did not indicate when the assessment was performed. The interview with Testing Person C on 5/26/20 at 12: 45pm confirmed the date was not on the assessment forms. 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 --