Summary:
Summary Statement of Deficiencies D6054 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(9) The technical consultant is responsible for evaluating and documenting the performance of individuals responsible for moderate complexity testing at least annually, after the first year. This STANDARD is not met as evidenced by: Based on review of the policy and procedure manual, review of personnel files, and staff interview on 02/26/2019, the technical consultant failed to perform and document annual competency assessments on five of five testing personnel listed on the Laboratory Personnel Report (CMS 209). Findings include: Review of the laboratory policy and procedure manual revealed "Competency will be evaluated at least semiannually during the first year the employee tests patient specimens. Thereafter, evaluation will be performed annually for each laboratory test a person performs. Competency evaluations can be performed onsite by technical consultants (TC). Review of personnel files failed to include annual competency assessments for the five testing personnel in 2018. Staff acknowledged in an interview at 1:30 PM on 02/26/2019, the laboratory failed to have a system in place to ensure established policy was followed and competency assessments were performed on all testing personnel 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 --