Ricks Advanced Dermatology & Skin Surgery Pa

Summary Statement of Deficiencies D6120 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(7)(8) (7) The technical supervisor is responsible for identifying training needs and assuring that each individual performing tests receives regular in-service training and education appropriate for the type and complexity of the laboratory services performed; (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 a review of competency assessment records, CMS Form 209, and interview, the technical supervisor failed to ensure that all six required elements for competency assessment were performed for seven of seven testing personnel (TP). Findings: 1. Competency assessments in 2023 and to date of survey for TP #1, 2, 3, 4, 5, 6, and 7 did not contain the following required elements: a. Direct observations of routine patient test performance, including patient preparation, if applicable, specimen handling,processing and testing; b. Monitoring the recording and reporting of test results; c. Review of intermediate test results or worksheets, quality control records, proficiency testing results, and preventative maintenance records; d. Direct observation of performance of instrument maintenance and function checks; e. Assessment of test performance through testing previously analyzed specimens, internal blind testing samples or externalproficiency testing samples; and f. Assessment of problem solving skills. 2. All seven TP have performed mycology (KOH) testing. 3. Interview with the Business Manager on 8/12/24 at 10:25 a.m. confirmed, the technical supervisor failed to ensure that all six required elements for competency assessment were performed for seven of seven testing personnel (TP). 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 --

Summary Statement of Deficiencies D5200 GENERAL LABORATORY SYSTEMS CFR(s): 493.1230 Each laboratory that performs nonwaived testing must meet the applicable general laboratory systems requirements in 493.1231 through 493.1236, unless HHS approves a procedure, specified in Appendix C of the State Operations Manual (CMS Pub. 7), that provides equivalent quality testing. The laboratory must monitor and evaluate the overall quality of the general laboratory systems and correct identified problems specified in 493.1239 for each specialty and subspecialty of testing performed. This CONDITION is not met as evidenced by: Based on review of proficiency testing (PT) and interview, the laboratory failed to evaluate proficiency testing performance (refer to D5217). D5217 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(c)(1) At least twice annually, the laboratory must verify the accuracy of any test or procedure it performs that is not included in subpart I of this part. This STANDARD is not met as evidenced by: Based on review of proficiency testing (PT) and interview with the office manager the laboratory failed to twice annually, verify the accuracy of pathology for 2017 to date November 11, 2018. 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 --