Summary:
Summary Statement of Deficiencies D6051 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(8)(v) The procedures for evaluation of the competency of the staff must include, but are not limited to assessment of test performance through testing previously analyzed specimens, internal blind testing samples or external proficiency testing samples. This STANDARD is not met as evidenced by: Based on record review and staff interview, the laboratory failed to ensure all testing personnel (TP) have tested unknown samples to demonstrate competency in performing laboratory tests in the specialty of microbiology. Findings Include: 1. Record review of the College of American Pathologists (CAP) 2017 Microbiology /Throat culture attestation sheets on 3/14/19 revealed 2 of 3 TP did not examine proficiency testing material to accurately assess their skills in 2017. 2. Record review of employee competency records on 3/14/19 revealed 2 of 3 TP did not examine previously analyzed specimens, internal blind testing samples or external proficiency testing samples to accurately assess their skills in 2017. 3. Staff interview with the clinical nurse supervisor on 3/14/19 at 9:45 AM confirmed the above TP had not examined unknown samples including proficiency testing material to accurately assess their skills in the specialty of microbiology in 2017. 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: Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 2 -- Based on record review and staff interview, the laboratory failed to document annual competency of testing personnel (TP) to assess their knowledge and skills necessary to perform throat cultures. Findings include: 1. Laboratory competency record review on 3/14/19 revealed annual competency documentation for 3 of 3 TP was not available for 2018. 2. Staff Interview with clinical nurse supervisor (CNS) on 3/14/19 at 10:00 AM confirmed the laboratory did not have annual competency documentation available for 3 of 3 TP in 2018. CNS stated competency was performed for TP in 2018 but unable to locate the documentation. 3. The laboratory performs 1279 throat cultures annually in the specialty of microbiology. -- 2 of 2 --