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 review of form CMS-209, review of 2016, 2017 and 2018 laboratory personnel competency records, review of 2016 surveyor notes and interview with laboratory manager assistant 05/15/18, the technical consultant (laboratory director) failed to perform annual competency evaluations on 5 of 6 testing personnel. Review of form CMS-209, laboratory personnel report, submitted at time of survey revealed 6 practitioners listed as testing personnel, including the technical consultant (laboratory director). Review of 2016, 2017 and 2018 laboratory personnel competency records failed to reveal competency assessments for 5 of 6 testing personnel. Review of 2016 surveyor notes revealed the laboratory was notified of the lack of competency evaluations for testing personnel and a competency brochure and a guidebook for provider performed microscopy procedures (PPMP) was given to the laboratory at time of 2016 survey. Interview with laboratory manager assistant at approximately 10: 30 am confirmed the laboratory had been supplied with a competency brochure and a PPMP guidebook. The laboratory manager assistant stated she "must have misunderstood" and she "thought the practitioners' split sample proficiency testing was record of competency." 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 --