Summary:
Summary Statement of Deficiencies D0000 An announced CLIA validation survey was conducted at Cancer Specialist of Tidewater-Suffolk on April 16, 2019 by the Virginia Department of Health's Office of Licensure and Certification. The laboratory was surveyed under 42 CFR part 493 CLIA Requirements. Specific deficiencies cited are as follows: 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 a review of the Centers for Medicare and Medicaid Services Laboratory Personnel Report form (CMS 209), laboratory personnel files, and interviews, the technical consultant (TC) failed to document training and competency assessment records for one (1) of three (3) testing personnel (TP) in the twenty-four (24) months reviewed. Findings include: 1. Review of the CMS 209 form revealed that the lab director (LD) performs the duties of TC. An interview with the LD at approximately 2: 00 PM revealed that 3 TP performed hematology testing during the 24 months reviewed (March 2017-March 2019) and were included on the CMS 209. 2. Review of the laboratory's 2017 and 2018 personnel files revealed no hematology training or competency assessments available for TP A. The inspector requested to review initial training and hematology competency assessment documentation for TP A. The documentation was not available for review. (See Personnel Code Sheet) 3. In an exit interview with the LD, at approximately 3:30 PM, the above findings were confirmed. 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 --