Planned Parenthood Great Northwest, Hi, Ak, In, Ky

CLIA Laboratory Citation Details

1
Total Citation
1
Total Deficiency
1
Unique D-Tag
CMS Certification Number 18D0663627
Address 268 Southland Drive, Suite 120, Lexington, KY, 40503
City Lexington
State KY
Zip Code40503
Phone(800) 769-0045

Citation History (1 survey)

Survey - August 17, 2018

Survey Type: Standard

Survey Event ID: JIH011

Deficiency Tags: D6046

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 personal. Competency assessment was performed using zero (0) of six (6) methods of assessment for two (2) out of Two (2) employees from April 11, 2017 through August 16, 2018. Findings include: Record review on 08 /17/18 revealed there was no documented evidence of competency assessments between April 11, 2017 and Aug 16, 2018, for two (2) employees that included the following: 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 maintenance records; assessment of testing external proficiency testing samples and problem solving skills. Interview with staff on 08/17/18 at 08:46 AM, revealed the facility failed to have a system in place between April 11, 2017 and Aug 16, 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 --

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