Tennessee Pediatrics

CLIA Laboratory Citation Details

1
Total Citation
1
Total Deficiency
1
Unique D-Tag
CMS Certification Number 44D0944132
Address 410 North Parrish Place Suite 2000, Hendersonville, TN, 37075
City Hendersonville
State TN
Zip Code37075
Phone(615) 826-2080

Citation History (1 survey)

Survey - August 28, 2018

Survey Type: Standard

Survey Event ID: 5Z3511

Deficiency Tags: D6046

Summary:

Summary Statement of Deficiencies D6046 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(8) (b) The technical consultant is responsible for-- (b)(8) Evaluating the competency of all testing personnel and assuring that the staff maintain their competency to perform test procedures and report test results promptly, accurately and proficiently. This STANDARD is not met as evidenced by: Based on a review of Centers for Medicare & Medicaid Services (CMS) 209 personnel form, testing personnel (TP) competency records and an interview with the lead testing person, the laboratory's Technical Consultant failed to sign and approve semi-annual and annual competency assessment in the specialty of Hematology for complete blood count (CBC) for 12 of 12 testing personnel in 2016, 2017 and 2018. Findings include: 1. Review of the CMS 209 revealed 12 TPs reporting CBC results from 2016-2018. 2. Review of testing personnel competencies revealed the Technical Consultant failed to sign and approve semi-annual competencies for 4 out of 12 testing personnel in their 1st year of 2017-18. 3. Review of testing personnel competencies revealed the Technical Consultant failed to sign and approve annual technical competencies for 8 of 12 testing personnel for 2016, 2017 and 2018. 4. In an interview, August 28, 2018, at approximately 12:30 PM, the lead testing person confirmed the Technical Consultant failed to sign and approve semi-annual and annual technical competency assessment for 12 of 12 testing personnel competencies in 2016, 2017 and 2018. 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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