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 review of records for 2019 and 2020 and interview, the laboratory failed to verify the accuracy of Mohs testing twice per year. Findings include: 1. The laboratory uses peer review to monitor the accuracy of Mohs testing. 2. Peer review documentation was reviewed for 2019 and 2020. 3. Documentation revealed that slides were sent out for peer review in March of 2019 and May of 2020. Missing was documentation for the second peer reviews in 2019 and 2020. 4. 892 Mohs surgeries were performed in 2020. 5. The laboratory director confirmed these findings on 2/9 /2021 at 3:00 pm. 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 --