Summary:
Summary Statement of Deficiencies D0000 The following deficiencies were cited during a recertification survey completed on 03 /09/2021 for the federal requirements of 42 CFR Part 493 for Laboratories. 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 the review of personnel records, CMS (Centers for Medicare & Medicaid Services) Personnel Report Form 209, email and interview with the Technical Consultant, the Technical Consultant failed to perform competency evaluations for 2 Testing Personnel (TP#1 and TP#8) of 8 (TP#1-TP#8)Testing Personnel. Maybe indicated what lab this is Finding are: A. Review of personnel records revealed that portions of the annual competencies were performed at sister laboratories and not at this laboratory location. 1. TP #1 2019 What does the year mean? The competency for- Alere Triage (used for performing cardiac screening tests), Quality Control and maintenance records had Lab A as the location. The 2020 competency contained a CBC (Complete Blood Count ) printout from Lab E. 2. TP #8 2019 competancy for Alere Triage was performed at Lab C and the 2020 competancy was performed at Lab D. B. During interview on 03/09/2021 at 9:10 am,, the Technical Consultant confirmed this finding. C. Review of an email dated 03/15/2021 from the Technical Consultant indicated: TP#1 was hired for this laboratory location on 05/27/2018; TP#2 was hired for this laboratory location on 01/06/2019. D9999 Laboratory Identifiers Atrisco Lab A Paradise Lab B Las Estancias Lab C Northside Lab D Santa Fe Lab E 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 --