Summary:
Summary Statement of Deficiencies D5891 POSTANALYTIC SYSTEMS QUALITY ASSESSMENT CFR(s): 493.1299(a) The laboratory must establish and follow written policies and procedures for an ongoing mechanism to monitor, assess and, when indicated, correct problems identified in the postanalytic systems specified in 493.1291. This STANDARD is not met as evidenced by: Based on lack of Quality Assessment (QA) documentation from 2022, 2023 and 2024 and interview with the facility personnel, the laboratory failed to follow established policies and procedures for an ongoing mechanism to monitor, assess and, when indicated, correct problems identified in the postanalytic systems. Findings include: 1. The laboratory's Post-Analytical Quality Assessment policy states, "On a quarterly basis, applicable laboratory personnel will review ten (10) percent of cases done during the previous quarter. This process will include pulling the patient charts, the Mohs log, and slides. They will be checked to make sure that the op-report, map, Mohs log and slides are accurate. If there are any discrepancies, it will be noted on LF- 0011 Quarterly QA Form and