Summary:
Summary Statement of Deficiencies D6053 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(9) (b)(9) 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 review of personnel evaluation records and an interview with Technical Consultant (TC), the TC failed to assess and document the 2024 semi-annual competency for one of the seven Testing Personnel (TP) responsible for the urine sediment examination during the first year of patient testing. The findings include: 1. A review of personnel evaluation records for TP listed on the CMS-209 Form (Laboratory Personnel Report) revealed the TC failed to perform and document the 2024 semi-annual competency assessment for TP6 in the first year of patient testing. 2. During the exit conference on 01-21-2026 at 12:30 PM, the TC confirmed the above findings. D6054 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(9) (b)(9) Thereafter, evaluations must be performed at least annually This STANDARD is not met as evidenced by: Based on review of personnel evaluation records and an interview with the Technical Consultant (TC), the TC failed to assess and document the annual competency for five of the seven Testing Personnel (TP) responsible for the urine sediment examination from 2024-2025. The findings include: 1. A review of personnel evaluation records for TP listed on the CMS-209 Form (Laboratory Personnel Report) revealed the TC 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 -- failed to perform and document the annual competency assessments for the urine sediment examinations for the following TP: A) TP3, TP5, TP7 in 2024 and 2025 B) TP4, TP6 in 2025 2. During the exit conference on 01-21-2026 at 12:30 PM, the TC confirmed the above findings. -- 2 of 2 --