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 surveyor review of twice-annual accuracy evaluation records from 2018 and 2019 and interview with laboratory staff, the laboratory did not verify the accuracy of the dermatopathology diagnostic slide interpretations performed with frozen section evaluations. Additionally, the laboratory did not have documentation showing the second annual review of Mohs testing in 2018. Findings include: 1. Review of accuracy evaluation records showed no evidence of evaluation in 2018 or 2019 for diagnostic dermatopathology slide interpretations. Further review showed no documentation of a second review of Mohs testing in 2018. 2. Interview with the laboratory staff, staff A, on January 3, 2020 at 2:10 PM confirmed the laboratory did not perform twice-annual accuracy evaluation of diagnostic dermatopathology slide interpretations in 2018 or 2019 and could not produce documentation of the second Mohs evaluation in 2018. 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 --