Summary:
Summary Statement of Deficiencies D0000 A Recertification Survey was initiated and concluded on 07/13/2023. The facility was found not to be in compliance with the laboratory requirements of 42 CFR Part 493 with deficiencies cited. 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 review of the laboratory's CMS 209, personnel files and interview, the laboratory failed to ensure competency assessments were completed for five (5) of fifteen (15) personnel files reviewed. The findings include: Review of the CMS-209, signed by the Laboratory Director and dated 07/11/2023, revealed five (5) employees held the position of clinical consultant (CC). Review of personnel files for CC #1, CC #2, CC #3, CC #4, and CC #5, revealed no documented evidence of a competency assessment. During an interview, on 07/13/2023 at 11:15 AM, the Nursing Supervisor and the Laboratory Coordinator stated they were unaware that competency assessments should be performed for individuals who served as Clinical Consultants. 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 --