Summary:
Summary Statement of Deficiencies D0000 This Statement of Deficiencies was created as a result of an on-site CLIA recertification survey conducted at your facility on March 23, 2022. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. 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 a review of the 2020 laboratory records of the twice per year verification of accuracy for Mohs testing, and an interview with the practice manager, the laboratory failed to ensure that the twice per year verification of accuracy was completed for one of one testing personnel performing Mohs testing during 2020. Findings include: 1. There was no documentation of the twice per year verification of accuracy for testing person number two listed on the CMS-209 form for Mohs testing during 2020. The testing personnel performed Mohs testing on October 23, 2020, and December 11, 2020. 2. The findings were confirmed during an interview with the practice manager conducted on March 23, 2022 at approximately 9:15 AM. The laboratory performs approximately 240 histopathology tests 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 --