Summary:
Summary Statement of Deficiencies D0000 An announced CLIA Validation survey was conducted at the University Pathology Associates DBA PRW Laboratories on May 23 & 24, 2023 by the Virginia Department of Health's Office of Licensure and Certification. The laboratory was surveyed under 42 CFR part 493 CLIA Requirements. Specific deficiencies cited are as follows: 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 the review of the Laboratory Personnel Report Form (CMS-209 Form), policy and procedures (P&P), personnel competency assessment records, lack of documentation and interviews, the laboratory failed to establish a competency policy to evaluate personnel that held the supervisory position of general supervisor (GS) listed on the CMS-209 Form at the dates of survey on May 23 & 24, 2023. Findings include: 1. Review of the CMS-209 Form revealed one GS. 2. Review of P&P revealed lack of documentation of an established policy for performing competency assessments of personnel designated for the role of GS. In an interview with the GS on 05/23/23 at approximately 12:30, they stated that they had a competency assessment for the technical component of testing but not for their role as GS. 3. An exit interview with the lab director and GS on 05/24/23 at approximately 12:30 confirmed the findings. 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 --