Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 01D0027451 (X3) Date Survey Completed 08/24/2023
Name of Provider or Supplier Grove Hill Memorial Hospital Street Address, City, State 295 S Jackson St, Grove Hill, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies
D6046 TECHNICAL CONSULTANT RESPONSIBILITIES
CFR(s): 493.1413(b)(8)

(b) The technical consultant is responsible for-- (b)(8) Evaluating the competency of all testing personnel and assuring that the staff maintain their competency to perform test procedures and report test results promptly, accurately and proficiently.


This STANDARD is not met as evidenced by:
Based on a review of Testing Personnel records and an interview with the Technical Consultant, the Technical Consultant failed to implement and document evaluations that included the six minimal regulatory requirements for assessment of competency for all moderately complex testing. This was noted for eight out of eight Testing Personnel from May 2022 to the date of the current survey (08/24/2023). The findings include: 1. A review of Testing Personnel records revealed a form titled "Laboratory Competency/Performance Checklist" which included direct observation of the following criteria under "Laboratory Equipment": "1. Can perform daily maintenance on all lab equipment, 2. Can perform weekly/monthly/as needed maintenance on all lab equipment, 3. Performs daily QC and investigates problems if needed, 4. Can perform routine testing on each instrument in the laboratory, 5. Can replace reagents on each lab instrument. The form failed to include an assessment of "Monitoring the recording and reporting of test results", and "Assessment of test performance through testing previously analyzed samples". 2. During an interview at 4:00 PM on 08/23/2023, the Technical Consultant confirmed the aforementioned form was used as a competency assessment for Testing Personnel.