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 the surveyor's review of the laboratory's records for evaluation of proficiency testing performance and an interview with laboratory personnel (LP) on 12 /3/2021 between 9 a.m. and 10 a.m., it was determined that the laboratory failed to at least twice annually, document their quality assurance/proficiency peer review testing for the year 2020. Findings include: 1. On 12/3/21, an inspection was conducted between 9 a.m. and 10 a.m. 2. During a review of the laboratory quality documentation, it was noted at approximately 9:30 a.m. that the laboratory failed to document peer proficiency testing for MOHS/ Histopathology in 2020. 3. The LP recognized that this documentation was missing. 4. MD peer review documentation was present for 2021 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 --