Summary:
Summary Statement of Deficiencies D5203 SPECIMEN IDENTIFICATION AND INTEGRITY CFR(s): 493.1232 The laboratory must establish and follow written policies and procedures that ensure positive identification and optimum integrity of a patient's specimen from the time of collection or receipt of the specimen through completion of testing and reporting of results. This STANDARD is not met as evidenced by: Based on record review and interview with risk manager, histopathology laboratory MOHS operative report failed to have correct chart number for one of ten patient-test report reviewed. The findings include: On June 20, 2018 at 11:30am, reviewed ten patient -test reports (#1 to #10) for MOHS surgery that included; -MOHS operative report, -progress notes, -consent for MOHS surgery and repair, -MOHS map, -work log, -slides. Operative report for #10 from 7/6/17 had chart # as M-18-87, which would have been a chart number for year 2018 and not for year 2017. During an interview on June 20, 2018 at 1:15 PM, risk manager confirmed that operative report for MOHS operative report #10 from 7/6/17 had chart # as M-18-87, which would have been a chart number for year 2018 and not for year 2017. D6128 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 annually after the first year, unless test methodology or instrumentation changes, in which case, prior to reporting patient test results, the individual's performance must be reevaluated to include the use of the new test methodology or instrumentation. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 2 -- This STANDARD is not met as evidenced by: Based on record review and interview with risk manager, the technical supervisor did not perform an annual competency review for one of four testing personnel for two- year record period. The findings include: During the personnel record review for four personnel at 11:30AM on June 20, 2018, for the review period 2016 to 2018, one testing person did not have yearly competency evaluation performed from year 2016 to June 20, 2018. During an interview on June 20, 2018 at 1:15 PM, risk manager confirmed that technical supervisor did not perform an annual competency review for one of four testing personnel from years 2016 to 2018- two-year record period. -- 2 of 2 --