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 the review of the laboratory policies, review of 2019, 2020, and 2021 laboratory records and absence of documentation, and interview with the histology technician 10/21/21, the laboratory failed to verify the accuracy of Mohs testing at least twice a year in 2020. Findings: The laboratory policy, "Proficiency Testing Mohs Micrographic Surgery Skin Specimens" states "Semi-annually, the tech or Risk Manager will send two cases containing the original slides, label it with only the surgical case number, and send it out for a microscopic examination by a Board Certified Pathologist." Review of the Proficiency Testing laboratory records revealed verification of accuracy of Mohs testing was performed in May 2020 and not again until April 2021. There was no documentation that the laboratory had verified accuracy of Mohs testing for a 2nd time in 2020. At approximately 12 p.m., the Histology technician confirmed the 2nd set of cases were not sent out in 2020. 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 --