Summary:
Summary Statement of Deficiencies D0000 Noted deficiencies and plans of correction were discussed with the laboratory representative(s) at the exit conference. The facility representative(s) were given an opportunity to provide evidence of compliance with the noted deficiencies, and no such evidence was provided prior to survey exit. The facility was found to be in compliance with applicable Conditions of Participation in the CLIA program, and recertification is recommended. 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 laboratory policy and records and confirmed in interview, the laboratory failed to verify the accuracy of all test procedures it performs that are not regulated analytes, at least twice annually. (Mohs) Findings were: 1. A review of the laboratory policy Procedure and Form 10: MOHS Biannual Slide review under frequency revealed "biannually; each calendar year. January and July are the designated months." 2. A review of the laboratory records revealed 1 of 2 Biannual slide review for 2017 and 1 of 2 biannual slide review for 2018. No documentation of the second review for the year 2017 and 2018. 3. An interview of the practice administrator on 3/4/19 at 0940 hours in the laboratory confirmed the above findings. 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 --