Summary:
Summary Statement of Deficiencies D6054 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(9) The technical consultant is responsible for evaluating and documenting the performance of individuals responsible for moderate complexity testing at least annually, after the first year. This STANDARD is not met as evidenced by: Through review of personnel records, lack of documentation and interview it was determined that the laboratory failed to evaluate competency on an annual basis of one of ten testing personnel listed on the CMS 209 form. Findings follow: A) Review of the records of competency evaluation for the testing person, identified as personnel number eleven on the CMS 209 form, revealed competency evaluations dated 7/12 /2019 and 1/31/2020. There were no competency evaluations documented after 1/31 /2020. B) Upon request, the laboratory was unable to provide competency evaluations after the one dated 1/31/2020 for laboratory employee number eleven. C) In an interview on 4/29/2021 at 10:12 a.m. the laboratory staff member, identified as number two on the CMS 209 form, confirmed that the laboratory testing personnel, identified as number three on the CMS 209 form, did not have competency documented after 1/31/2020 (15 months). 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 --