Dermatology Associates Of Tallahassee

Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at Dermatology Associates of Tallahassee on 11/04/2025. The laboratory was surveyed under 42 CFR Part 493 CLIA requirements. Standard deficiencies cited are as follows: D5209 PERSONNEL COMPETENCY ASSESSMENT POLICIES CFR(s): 493.1235 As specified in the personnel requirements in subpart M, the laboratory must establish and follow written policies and procedures to assess employee and, if applicable, consultant competency. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the Laboratory performs annual competency testing, that includes the grossing portion of histology testing, and are not signed off for 3 of 3 Testing Persons (TP#A, TP#B, TP#C) for 2 of 2 (2024- 2025) years. Findings Include: 1.) Review of CMS-209 Personnel form, signed by the Laboratory Director (LD) 10/16/2025, lists 3 high complexity TP (TP#A, TP#B, TP#C). 2.) Review of the "Employee Training and Evaluation" procedure, states annual evaluations are to be signed by "lab manager and the employee." 3.) Review of annual competencies performed on TP# A on 7/23/24 and 7/22/25 revealed no signature for review. Review of TP#B annual competencies performed on TP#B on 7 /23/24 and 7/22/25 revealed no signature for review. Review of TP#C annual competencies performed on 7/23/24, and 7/22/25 revealed no signature for review. 4.) Interview with TP#A at 11:07am on 11/4/25 recognized that annual competencies were not signed. 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 --

Summary Statement of Deficiencies D0000 A recertification survey was conducted on 8/3/21. Dermatology Associates of Tallahassee (Marianna location) was found 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 review of QA (Quality Assurance) peer review and staff interview, the laboratory failed to verify the accuracy of DTM (Dermatophyte Test Medium) testing, and Mohs testing at least twice a year for 1 of 2 (2019-2021) years reviewed. The findings include: 1. Review of peer review records found peer review for DTM testing was not performed in 2020. Interview with Testing Person A on 8/3/21 at approximately 8:45 a.m. confirmed that peer review for DTM was not performed in 2020. 2. Review of peer review records found peer review for Mohs testing was only performed once in 2020. The interview with Testing Person A on 8/4/21 at 8:45am confirmed that Mohs peer review was only performed once. 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 --