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 review of four Mohs surgery cases and interview with the facility personnel, the laboratory failed to indicate the correct number of stages on the Mohs operative report for one of the four Mohs cases reviewed. Findings include: 1. The Mohs Map and Mohs Slides ID #18-0122 (03/13/2018) indicated a total of two stages performed while the Mohs operative report indicated a third stage was performed. 2. There was no