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 observation, record review and staff interview, the laboratory failed to provide documentation for biannual accuracy verification for Mohs and frozen sections in the subspecialty of histopathology. Findings include: 1. Observation of the laboratory documentation on 11/7/18 at 1:30 PM revealed the laboratory lack the biannual accuracy verification for Mohs and frozen sections in 2017. 2. Record review of the laboratory's procedure on 11/7/18 revealed slides are sent out for review of accuracy biannually. 3. Staff interview with laboratory manager on 11/7/18 at 1:30 PM confirmed the above findings. 4. The laboratory performs 510 histopathology test annually. 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 --