Summary:
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 record review and interview with the Lab Manager, the laboratory failed to have competency evaluations for 1 of 1 Cytology General Supervisor, 1 of 1 Technical Supervisor for Parasitology, Virology, and Cytology, and 2 (#B and #C) out of 12 (#A-#L) Testing Personnel for 2 out of 2 (2016-2017) years reviewed. Findings Included: Review of employee competency documentation found no competency evaluations for the Cytology General Supervisor, the Technical Supervisor over Parasitology, Virology, and Cytology (who is also Testing Person #B), and on Testing Personnel #B and #C. During an interview on 03/15/18 at 5:15 PM the Lab Manager confirmed that there were no competencies performed on the employees listed above during the last 2 years. 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 --