Summary:
Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at Alexandria Associates in Dermatology (AAID) on August 4, 2022 by the Virginia Department of Health's Office of Licensure and Certification. The laboratory was surveyed under 42 CFR part 493 CLIA Regulations. The specific deficiency is as follows: D3031 RETENTION REQUIREMENTS CFR(s): 493.1105(a)(3) Analytic systems records. Retain quality control and patient test records (including instrument printouts, if applicable) and records documenting all analytic systems activities specified in 493.1252 through 493.1289 for at least 2 years. This STANDARD is not met as evidenced by: Based on review of the laboratory's Mohs surgery log book, electronic medical records, lack of documentation and interviews, the laboratory failed to retain a copy of the patient's Mohs surgery map in the patient's electronic medical record (EMR) for three (3) of twelve (12) Mohs surgery patients selected from January 1, 2021 until August 4, 2022. Findings include: 1. The surveyor selected 12 Mohs surgery patients from January 1, 2021 until August 4, 2022 for review: AA21-33, AA21-34, AA21-35, AA21-36, AA21-037, AA21-038, AA21-039, AA21-040, AA21-041; AA21-151; AA22-075 and AA22-097. 2. Review of each of the above listed patient EMRs revealed a lack of documentation of the Mohs surgery map for the following Mohs surgery patients: AA21-033, AA21-035 and AA21-037. A total of 3 patients. The inspector requested to review documentation of the Mohs surgery maps for AA21- 033, AA21-035 and AA21-037. The laboratory provided no documentation of the above listed Mohs surgery maps to review. In an interview with the Practice Administrator on August 4, 2022 at approximately 10:30 AM, the office manager stated "The Mohs maps are scanned to the patient's chart. Once the Mohs map is scanned to the patient's EMR, the paper copy is shredded. I am unsure what happened to those Mohs maps. I have spoken to the Clinical Manager and we have discussed Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 2 -- how to ensure the maps are scanned to the patient's EMR." 3. In an exit interview with the Practice Administrator on August 4, 2022 at approximately 11:00 AM, the above finding was confirmed. -- 2 of 2 --