Triad Behavioral Resources, Pc

Summary Statement of Deficiencies 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 policies and procedures, review of personnel records, and interview with GS (general supervisor) #2 on 1/14/25, the laboratory failed to follow written policies for evaluating the competency of personnel. Findings: Review of the laboratory's "General Policies and Procedures" revealed "SECTION 1 - PERSONNEL ... 1.2 Competency Assessment... Documented competency assessments will be performed on all persons that perform patient testing and/or report patient test results. At a minimum, this includes technical and clinical consultants, technical supervisors, general supervisors and testing personnel. The Technical Supervisor/Laboratory Director is responsible for performing and documenting competency assessments. ..." Review of personnel records for GS #2 revealed the 2024 GS and testing personnel competency evaluations were not signed to indicate who performed the evaluations. During interview at approximately 3:30 p.m., GS #2 stated the competency evaluations were done, but she was unsure why they had not been signed. 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 --

Summary Statement of Deficiencies D5403 PROCEDURE MANUAL CFR(s): 493.1251(b) The procedure manual must include the following when applicable to the test procedure: (1) Requirements for patient preparation; specimen collection, labeling, storage, preservation, transportation, processing, and referral; and criteria for specimen acceptability and rejection as described in 493.1242. (2) Microscopic examination, including the detection of inadequately prepared slides. (3) Step-by-step performance of the procedure, including test calculations and interpretation of results. (4) Preparation of slides, solutions, calibrators, controls, reagents, stains, and other materials used in testing. (5) Calibration and calibration verification procedures. (6) The reportable range for test results for the test system as established or verified in 493.1253. (7) Control procedures. (8)