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 surveyor review of procedures and quality assurance records and interview with the clinic manager and histotechnologist, the laboratory did not evaluate the accuracy of the diagnosis for Mohs testing for two of two events in 2020. Findings include: 1. Review of the "Proficiency Testing" procedure stated, "This review will include assessment of the quality of slide preparation, diagnostic agreement and Mohs map accuracy". 2. Review of the "Mohs North Quality Assurance/Mohs Slide Interpretation Review" worksheets for 2020 showed no review of diagnostic agreement for Mohs cases. 3. Interview with Staff A and B on November 24, 2020 at 9:17 AM confirmed the review of accuracy for Mohs testing did not include diagnostic agreement for two of two events 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 --