HospitalInspections.org

Based on interview and record review the facility failed to evaluate staff performance through annual evaluations/competencies, provide pertinent ongoing staff education and verify certifications for all radiology staff.
This had the potential to put all patients at risk of receiving radiology services that were inadequate or erroneous by potentially unqualified staff. There were six radiology staff who required certification at the time of the survey. The facility census was 52.

Findings included:

These failures were initially mentioned (not cited) to the facility administrative staff at an exit on 04/22/19, again at an exit on 06/11/19, and the facility failed to be in compliance as of exit on 07/24/19.

Record review of two radiology technician's personnel files (Staff J and K) showed no evidence of any annual evaluation or competencies, and no certification verification.

During an interview on 07/23/19 at 8:55 AM, Staff H, Radiology Director, stated that they had never done annual evaluations or competencies, and she was not sure what that entailed. She stated that she had asked another facility for an example of their education content and related documentation for reference; however, she had not instituted anything.

During an interview on 07/24/19 at 2:12 PM, Staff H stated that her staff were required to complete continuing education units (CEU's), but CEU's were not documented or tracked. Staff H stated that there was no structured education or competencies. She stated that some of the radiology technicians were required to have a certification, with renewal every two years, but she did not track those certifications.