Summary:
Summary Statement of Deficiencies D6053 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 semiannually during the first year the individual tests patient specimens. This STANDARD is not met as evidenced by: Based on surveyor review of the CMS-209 testing personnel report, review of competencies, and an interview with the laboratory director, the technical consultant failed to perform semiannual competencies on three out of ten testing personnel performing moderate complexity testing. Findings are: 1. Review of the CMS-209 Laboratory Personnel Report revealed testing personnel #4 started testing on November 2022, testing personnel #7 started testing on March 2022, and testing personnel #10 started testing on June 2022. 2. Review of 2022 and 2023 competencies revealed testing personnel #4, #7, and #10 had no semiannual competencies performed. 3. Interview with the laboratory director on 12/5/2023 at 10:50 AM confirmed testing personnel #4, #7, and #10 had no semiannual competencies performed. 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 surveyor review of the CMS-209 testing personnel report, review of 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 -- competencies, and an interview with the laboratory director, the technical consultant failed to perform 2023 annual competencies on five out of ten testing personnel performing moderate complexity testing. Findings are: 1. Review of the CMS-209 Laboratory Personnel Report revealed ten testing personnel performing moderate complexity testing. 2. Review of 2022 and 2023 annual competencies presented at time of survey revealed testing personnel #1, #2, #4, #7, and #10 did not have 2023 annual competencies performed. 3. Interview with the laboratory director on 12/5 /2023 at 10:50 AM confirmed testing personnel #1, #2, #4, #7, and #10 did not have 2023 annual competencies performed. -- 2 of 2 --