Summary:
Summary Statement of Deficiencies D0000 Based on an on-site recertification survey conducted on May 23, 2025, deficiencies were cited for Colorado Skin Surgery and Dermatology in Centennial, Colorado. D5407 PROCEDURE MANUAL CFR(s): 493.1251(d) (d) Procedures and changes in procedures must be approved, signed, and dated by the current laboratory director before use. This STANDARD is not met as evidenced by: Based on review of the laboratory's policies and procedures manual, and an interview with the office manager (not on CMS Form 209), the laboratory director (LD) failed to ensure that the laboratory's policies and procedures manual for histopathology had been approved, signed, and dated by the current LD before use since the laboratory's previous recertification survey was conducted on July 16, 2021. The laboratory conducts approximately 1,000 histopathology tests annually. Findings include: 1. A review of the laboratory's policies and procedures manual for histopathology revealed that the current LD had not approved, signed, or dated the laboratory's policies and procedures for histopathology prior to their use in the laboratory. 2. Based on an interview with the office manager (not on CMS Form 209), on May 23, 2025 at approximately 10:30 AM, confirmed that the current LD had not reviewed, signed, and dated the laboratory's policies and procedures manual for histopathology prior to their use in the laboratory. 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 --