Summary:
Summary Statement of Deficiencies D5209 PERSONNEL COMPETENCY ASSESSMENT POLICIES CFR(s): 493.1235 As specified in the personnel requirements in subpart M, the laboratory must establish and follow written policies and procedures to assess employee and, if applicable, consultant competency. This STANDARD is not met as evidenced by: Based on a review of the Centers for Medicare and Medicaid Services (CMS) 209 personnel form, competency assessment records and an interview with the technical consultant (TC) on 8/13/2024, the laboratory failed to follow written policies and procedures to assess testing personnel competency in 2024. The findings include: 1. A review of the CMS 209 form identified three testing personnel. 2. A review of competency assessment records identified the laboratory failed to have documentation of a six month competency assessment for one testing personnel in 2024. 3. An interview with the TC on 8/13/2024 at 9:10 am confirmed the above finding. 4. The laboratory reports performing 1,534 hematology tests annually 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 --