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: Through review of the CMS 209 form, personnel records, and interview conducted on 6/19/2025 it was determined that the competency of the technical consultant was not assessed by the laboratory director on an annual basis. Findings follow: A) Review of personnel files revealed that the annual evaluation of the competency of the technical consultant listed on the CMS 209 was documented only once dated 10/26/2022 and no other documentation of technical consultant competency was presented. B) Upon request, the laboratory was unable to provide other competency evaluations of the technical consultant listed on the CMS 209 form after the evaluation identified above. C) In an interview on 6/19/2025 at 10:32 a.m. the technical consultant listed on the CMS 209 form said, "that no other competency evaluations were present and available". 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 --