Sacred Heart Health System, Inc

CLIA Laboratory Citation Details

1
Total Citation
2
Total Deficiencyies
2
Unique D-Tags
CMS Certification Number 10D0271069
Address 5190 Bayou Blvd St 7, Pensacola, FL, 32503
City Pensacola
State FL
Zip Code32503
Phone(850) 416-7000

Citation History (1 survey)

Survey - November 7, 2018

Survey Type: Standard

Survey Event ID: PSR711

Deficiency Tags: D0000 D5209

Summary:

Summary Statement of Deficiencies D0000 A recertification survey was conducted on November 7, 2018. Pediatric Associates PA clinical laboratory had one deficiency found at the time of the visit. 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 record review and interview with testing person # 8, the laboratory failed to ensure that clinical and technical consultants maintained competency based on duties and responsiblities, performance of test procedures and reporting of tests accurately for 7 out of 7 clinical and technical consultants reviewed. Findings included: Based on review of clincal and technical consultants # 2, 3, 4, 5, 6, 7, and 8 records revealed no competency evaluations for 2 years from November 2016 through November 2018. During interview on 11/7/18 at 10:30 AM , testing person # 8 confirmed that the lab failed to implement policies that will show competency evaluations for clinical and technical consultants and competencies were not done. 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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