Summary:
Summary Statement of Deficiencies D5217 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(c)(1) At least twice annually, the laboratory must verify the accuracy of any test or procedure it performs that is not included in subpart I of this part. This STANDARD is not met as evidenced by: Based on record review and interview with the Laboratory Manager, the laboratory failed to verify the accuracy of Histopathology testing at least every 6 months for 2 out of 2 years (2016-2018) reviewed. Findings Included: Policy and procedures revealed that Histopathology peer review should be performed every 6 months to verify the accuracy of testing. Peer reviews were conducted on 05/16, 01/17 (2 months late), and 06/17 (6 months late). No other peer reviews were performed. During an interview on 06/01/18 at 11:30 AM the Laboratory Manager confirmed that the peer reviews were not done timely per their policy. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 1 --