Summary:
Summary Statement of Deficiencies D0000 A CLIA recertification survey was conducted for Greater Metrowest DermSurgeons on 11/02/2023 for the laboratory pursuant to the Clinical Laboratory Improvement Amendments (CLIA) of 1988 and CLIA regulations at 42 CFR 493. 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 record review and interview with the Histology Technician on 11/02/2023, the laboratory failed to follow procedures and policies for twice annual verification of testing it performs that is not included in subpart I of this part as evidenced by the following: The surveyor reviewed the laboratory's procedure for Physician Quality Assurance policy for review of histopathology dermatology tissue slide cases. The review revealed that biannually within a calendar year histopathology slides of cases are randomly selected for accuracy review with a second Mohs surgeon. A review of calendar years 2022 and 2023 quality assessment records revealed all of 2022 slide case reviews were performed on 1/6/2023 and all of 2023 slide case reviews were performed on 10/17/2023. The Histology Technician interviewed on 11/02/23 at 10: 35AM confirmed that twice annual accuracy verification for histopathology dermatology tissue slide cases was not performed at least twice annually for calendar years 2022 and 2023. Laboratory performs 2128 Mohs Slide Exams annually. 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 --