Atlantic Dermatology, Pa

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 staff interview on 12/19/2024, the laboratory failed to document the performance of proficiency testing, verifying the accuracy of the KOH Procedure used to test skin scrapings from affected areas of patients to determine the presence of microorganisms. Findings: The absence of records to review for 2023 and 2024 revealed that the laboratory failed to perform proficiency testing or verification of accuracy of skin scrapings for microorganisms. The review of the laboratory Policy and Procedure Manual revealed the KOH Procedure was approved by the director on 05/30/2023. Under the section entitled, "Proficiency Testing ...#1. At least twice annually, the office participates in proficiency testing completed by each provider that performs this test ... #2. In-house testing is a peer review by another provider in the practice that participates in KOH testing. All testing interpretation are recorded on each provider's "Proficiency Testing Answer and Review Sheet for KOH" by the Clinical Supervisor. #4. The Laboratory Director reviews all proficiency testing for deficiencies. #5.

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 review of 2020, 2021, and 2022 laboratory records and interview with the histology technician 6/7/23, the laboratory failed to verify the accuracy of the Mohs histopathology testing at least twice a year during 2020, 2021, and 2022. Review of 2020, 2021, and 2022 laboratory records revealed the laboratory had participated in peer reviews of Mohs surgery cases to verify the accuracy of their Mohs histopathology testing. The peer reviews were performed only once per year in 2020, 2021, and 2022. During interview at approximately 11:00 a.m., the histology technician stated that the laboratory director had also participated in peer reviews at the laboratory's sister facility, so they were unaware he needed to participate at least twice a year at this location. 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 --