Summary:
Summary Statement of Deficiencies D5211 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(a) The laboratory must review and evaluate the results obtained on proficiency testing performed as specified in subpart H 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 10 /8/2021 between 11 am and 12:30 pm, 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 10/8/2021, an inspection was conducted between 11 am and 12:30 pm. 2. During a review of the laboratory quality documentation, it was noted at approximately 11:45 am. that the laboratory failed to document MD 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 --