Summary:
Summary Statement of Deficiencies D0000 A recertification survey was conducted on October 21, 2021. The Center for Skin Cancer Surgery Inc clinical laboratory was not in compliance with 42 CFR 493, requirements for clinical laboratories. 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, the laboratory failed to verify the accuracy of the reading and interpretation of the Hematoxylin and Eosin (H&E) stain for 1 of 2 required twice annual verification in 2020. Findings: The laboratory used peer review to verify the accuracy of the reading and interpretation of H&E stain for their Mohs surgery slides. Review of the procedure for "Proficiency Testing for Mohs" noted "Every six months, six to ten Mohs cases will be sent" to another dermatology laboratory "for interpretation of accuracy of diagnosis and quality of sections and stains." Review of the "Quality Review for Mohs" showed peer review was performed only on 09/01/2021 in 2020. On 10/21/2021 at 3:08 PM, the Histology Technologist stated peer review was performed only once in 2020 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 --