Summary:
Summary Statement of Deficiencies D5787 TEST RECORDS CFR(s): 493.1283(a) (a) The laboratory must maintain an information or record system that includes the following: (a)(1) The positive identification of the specimen. (a)(2) The date and time of specimen receipt into the laboratory. (a)(3) The condition and disposition of specimens that do not meet the laboratory's criteria for specimen acceptability. (a)(4) The records and dates of all specimen testing, including the identity of the personnel who performed the test(s). This STANDARD is not met as evidenced by: Based on record review and interview, the histopathology laboratory did not ensure that the patient information on the MOHS map, slides and patient log agreed. Findings: 1. There was discrepent information in the laboratory records for two of six patient records reviewed for patients who had under gone MOHS surgery. 2. MOHS surgery was performed on 7/31/2025 for patient #1. The slide for piece 3 of this case was labeled R pre auricular cheek, but slides for piece 1 and 2 (from this same case) were labeled as L central temple. 3. MOHS surgery was performed on 4/1/2025 for Patient #2. The case number on the patient log did not agree with the case number on the MOHS surgical map. 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 --