Summary:
Summary Statement of Deficiencies D0000 Recertification survey was conducted on April 29, 2024. Joseph J Chanda MD PA clinical laboratory was not in compliance with 42 CFR 493, requirements for clinical laboratories. 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 review of the procedure manual and peer review records, and interview, the laboratory failed to verify the accuracy of the reading and interpretation of the Hematoxylin and Eosin stain at least twice annually for 2022 and 2023. Findings: Review of the procedure titled, Quality Assurance/Proficiency Testing noted "Our lab's procedure dictates that a random selection of slides (approximately 3 -4 complete cases), twice per year, between state inspection periods are sent with a copy of the form following this narrative, to be evaluated by a designated clinical pathologist. Review of the peer review records revealed the peer review was done once in 2022 on 12/13/2022 and once in 2023 on 12/01/2023 . On 04/29/2023 at 4:15 PM, the Mohs Technician stated peer review was done only once in 2022 and 2023. 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 --