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 a records review and an interview with the Lead Mohs technician (not included on CMS-209 form), the laboratory failed in 2022 and 2023 to perform twice annual verification testing for Mohs histopathology slide interpretation, and Potassium Hydroxide (KOH) preparations. The laboratory performs approximately 200 Mohs histopathology procedures, and approximately 20 KOH preparations per year. Findings include: 1. Records review revealed that the laboratory failed to perform twice annual accuracy verification for Mohs histopathology slide interpretation, and Potassium Hydroxide (KOH) preparations for years 2022 and 2023. 2. An interview with the Lead Mohs technician (not included on CMS-209 form) at approximately 8: 45 AM on November 1, 2024, confirmed that the laboratory failed to perform twice annual accuracy verification for Mohs histopathology slide interpretation, and Potassium Hydroxide (KOH) preparations for years 2022 and 2023. 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 --