Summary:
Summary Statement of Deficiencies D5819 TEST REPORT CFR(s): 493.1291(j) All test reports or records of the information on the test reports must be maintained by the laboratory in a manner that permits ready identification and timely accessibility. This STANDARD is not met as evidenced by: Based on review of the Mohs operative report for Mohs case # 211-18 from 04/11 /2018, review of the frozen section biopsy log, and interview with the facility personnel, the laboratory failed to readily identify a frozen section biopsy that was indicated on the frozen section log as BX001-18 from 04/11/2018. Findings include: 1. There was no pathology report for the frozen section biopsy that indicated the case number BX001-18 as referenced on the frozen section log. 2. The Mohs operative report did refer to frozen section analysis with no residual tumor seen, but there was no reference to any case number or identification number for the biopsy analysis and there was no separate pathology report presented for BX001-18. 3. The facility personnel acknowledged that the frozen section referenced above was not readily identifiable from the documentation presented for review. 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 --