Utah Cancer Specialists-Main

CLIA Laboratory Citation Details

1
Total Citation
4
Total Deficiencyies
2
Unique D-Tags
CMS Certification Number 46D0524621
Address 3838 S 700 E Suite 100, Salt Lake City, UT, 84106
City Salt Lake City
State UT
Zip Code84106
Phone(801) 269-0231

Citation History (1 survey)

Survey - January 11, 2021

Survey Type: Standard

Survey Event ID: MDJ511

Deficiency Tags: D6033 D6035 D6033 D6035

Summary:

Summary Statement of Deficiencies D6033 TECHNICAL CONSULTANT-MODERATE COMPEXITY CFR(s): 493.1409 The laboratory must have a technical consultant who meets the qualification requirements of 493.1411 of this subpart and provides technical oversight in accordance with 493.1413 of this subpart. This CONDITION is not met as evidenced by: Based on competency evaluations review, lack of documentation, and interview with staff, the person performing competency evaluations for moderate complexity personnel failed to qualify as a moderate complexity technical consultant. See D6035. D6035 TECHNICAL CONSULTANT QUALIFICATIONS CFR(s): 493.1411 (a) The technical consultant must be qualified and must possess a current license issued by the State in which the laboratory is located, if such licensing is required. (b) The technical consultant must-- (b)(1)(i) Be a doctor of medicine or doctor of osteopathy licensed to practice medicine or osteopathy in the State in which the laboratory is located; and (b)(1)(ii) Be certified in anatomic or clinical pathology, or both, by the American Board of Pathology or the American Osteopathic Board of Pathology or possess qualifications that are equivalent to those required for such certification; or (b)(2)(i) Be a doctor of medicine, doctor of osteopathy, or doctor of podiatric medicine licensed to practice medicine, osteopathy, or podiatry in the State in which the laboratory is located; and (b)(2)(ii) Have at least one year of laboratory training or experience, or both in non-waived testing, in the designated specialty or subspecialty areas of service for which the technical consultant is responsible (for example, physicians certified either in hematology or hematology and medical oncology by the American Board of Internal Medicine are qualified to serve as the technical consultant in hematology); or (b)(3)(i) Hold an earned doctoral or master's 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 -- degree in a chemical, physical, biological or clinical laboratory science or medical technology from an accredited institution; and (b)(3)(ii) Have at least one year of laboratory training or experience, or both in non-waived testing, in the designated specialty or subspecialty areas of service for which the technical consultant is responsible; or (b)(4)(i) Have earned a bachelor's degree in a chemical, physical or biological science or medical technology from an accredited institution; and (b)(4)(ii) Have at least 2 years of laboratory training or experience, or both in non-waived testing, in the designated specialty or subspecialty areas of service for which the technical consultant is responsible. Note: The technical consultant requirements for "laboratory training or experience, or both" in each specialty or subspecialty may be acquired concurrently in more than one of the specialties or subspecialties of service, excluding waived tests. For example, an individual who has a bachelor's degree in biology and additionally has documentation of 2 years of work experience performing tests of moderate complexity in all specialties and subspecialties of service, would be qualified as a technical consultant in a laboratory performing moderate complexity testing in all specialties and subspecialties of service. This STANDARD is not met as evidenced by: Based on competency evaluations review, lack of documentation, and interview with staff, the person performing competency evaluations for moderate complexity personnel failed to qualify as a moderate complexity technical consultant. Findings include: 1. Competency evaluations for 5 moderate complexity testing personnel, (A, B, E, G, and H), in 2019 and 5 moderate complexity testing personnel in 2020, (A, B, C, D, and F), were performed by laboratory personnel who do not qualify as a technical consultant. 2. In an interview with staff on 01/11/2021 at approximately 2:00 P.M. the laboratory supervisor confirmed the person assessing competency for 5 testing personnel in 2019 and 5 testing personnel in 2020 did not qualify as a technical consultant. -- 2 of 2 --

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