Summary:
Summary Statement of Deficiencies D0000 Dermatology Associates of Tallahassee was found not to be in compliance with 42 CFR Part 493, Requirements for Laboratories as a result of a recertification survey on 8/2/2024. 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 the laboratory failed to perform competency evaluations on 3 (#A, #B, and #C) out of 3 Testing Personnel performing the moderately complex Mycology and Parasitology testing. Findings Include: Review of staff competency evaluations showed no competency evaluations performed on Testing Personnel #A, #B, and #C who performed the moderately complex Mycology and Parasitology testing. During the interview on 8/2/24 at 9:15 AM, laboratory staff confirmed that there were no competencies for Testing Persons #A, #B, and #C. 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 record review and staff interview, the laboratory failed to verify the accuracy of KOH (potassium hydroxide) testing at least twice a year in 2023. Findings Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 2 -- Include: Review of peer review records showed no documentation of twice annual verification of KOH testing in 2023. Interview with the laboratory staff on 8/2/24 at 9: 14am confirmed that no peer review was performed for KOH in 2023. -- 2 of 2 --