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 lack of accuracy verification documentation for Mohs and interview with the facility personnel, the laboratory failed to verify the accuracy of testing performed under the subspecialty of Histopathology at least twice annually during 2023. Findings include: 1. No documentation was presented for review to indicate the laboratory verified the accuracy of dermatopathology testing (performed in conjunction with the Mohs procedure) at least twice annually during 2023. 2. The facility personnel interviewed on 10/29/24 at 11:35 AM confirmed the laboratory failed to verify the accuracy of dermatopathology testing at least twice annually during 2023. 3. The laboratory's reported annual test volume in the subspecialty of histopathology is 900. 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 --