Summary:
Summary Statement of Deficiencies D5407 PROCEDURE MANUAL CFR(s): 493.1251(d) (d) Procedures and changes in procedures must be approved, signed, and dated by the current laboratory director before use. This STANDARD is not met as evidenced by: Based on review of the Mohs test procedure on 6/5/26 at 10:30 AM and interview with the facility personnel, the laboratory director failed to approve, sign and date the Mohs test procedure before use. Findings include: 1. The laboratory began testing on 10/17/25 and performs the microscopic interpretation of Mohs specimens under the subspecialty of Histopathology, with a reported annual test volume of 36. 2. An onsite review of the Mohs test procedure on 6/5/26 failed to include the approval, signature and date of the current laboratory director prior to patient testing on 10/17/25. 3. The facility personnel interviewed on 6/5/26 at 10:30 AM acknowledged that the Mohs test procedure was not approved, signed and dated by the current laboratory director before use. 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 --