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 review on record review, and interview with the laboratory manager the laboratory failed to blindly verify the accuracy of the MOHs procedure, not listed in Subpart I, at least twice annually. Findings Include: 1. Review of the laboratory's policy and procedure found no mention of blind MOHs test accuracy verification for clear margins. 2. An interview with the laboratory manager, on 1/18/18 at 1:01 pm, confirmed that the MOHs map was sent to the reviewer with proficiency test slides. Thus, the lab failed to blindly verify the accuracy of the MOHs procedure for clear margins at least twice annually, as required. 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 --