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, the Technical Consultant failed to perform and document annual competency using the six (6) mandated competency assessment requirements for testing personnel. Competency assessment was performed using zero (0) of six (6) methods of assessment for four (4) out of four (4) employees from September 8, 2016 through August 13, 2018. Findings include: Record review on 08/14/2018 revealed there was no documented competency assessments between September 8, 2016, and August 13, 2018, for four (4) employees that included the following: 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 08/14/2018 at 9:58 AM revealed the facility failed to have a system in place between September 8, 2016, and August 13, 2018, to ensure competency was performed using all six (6) mandated competency assessment requirements. 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 --