Summary:
Summary Statement of Deficiencies D6127 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(9) The technical supervisor is responsible for evaluating and documenting the performance of individuals responsible for high complexity testing at least semiannually during the first year the individual tests patient specimens. This STANDARD is not met as evidenced by: Based on review of testing personnel files, and interview of facility personnel, the Technical Supervisor failed to evaluate and document personnel competency at least semiannually during the first year the individual tests patient specimens for one of three testing personnel performing Mohs surgery procedures. The findings included: 1. Review of personnel files found testing person three (hired September 2019 )found one of two expected semiannual competency evaluations during the first year of testing. Personnel competency assessments for testing person three were dated 03/10 /2020, with the next one dated 03/11/2021. Additional documentation of competency assessments were requested but not provided. 2. Interview of testing person two listed on the CMS report 209 Laboratory Personnel Report conducted on March 23, 2021 at 1:41 PM confirmed that competency assessments had not been performed and documented at least semiannually for the first year of testing for testing person three. 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 --