Summary:
Summary Statement of Deficiencies D0000 Noted deficiencies and plans of correction were discussed with the laboratory representative(s) at the exit conference. The facility representative(s) were given an opportunity to provide evidence of compliance with the noted deficiencies, and no such evidence was provided prior to survey exit. The facility was found to be in compliance with applicable Conditions of Participation in the CLIA program, and recertification is recommended. D6128 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(9) The technical supervisor is responsible for evaluating and documenting the performance of individuals responsible for high complexity testing at least annually after the first year, unless test methodology or instrumentation changes, in which case, prior to reporting patient test results, the individual's performance must be reevaluated to include the use of the new test methodology or instrumentation. This STANDARD is not met as evidenced by: Based on review of the laboratory records and confirmed in interview, the technical supervisor failed to document an annual competency for 1 of 2 testing person (TP) for 2017 and 2018. Findings were: 1. Review of the laboratory CMS 209 revealed 2 testing personnel performing high complexity testing for Mohs. 2. Review of the laboratory personnel records available revealed no documentation of the 2017 and 2018 annual competency for 1 of 2 testing personnel (TP #2, hire date 7/2012). 3. An interview with the lab director on 4/18/19 at 1140 hours in the laboratory confirmed the above findings. key: CMS - centers for Medicare and Medicaid Services 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 --