Summary:
Summary Statement of Deficiencies D0000 A CLIA recertification survey was conducted for the Nantucket Dermatology LLC laboratory on 4/25/2025 pursuant to the Clinical Laboratory Improvement Amendments (CLIA) of 1988 and CLIA regulations at 42 CFR 493. . 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 record review and interview with the Office Manager (OM) on 4/25/2025, the laboratory failed to verify at least twice annually procedures it performs that are not included in subpart I of this part as evidenced by the following: The surveyor reviewed the laboratory's procedure and records for the twice annual peer slide review of histopathology Mohs slide examinations for calendar years 2023 and 2024. The laboratory procedure titled "Biannual Proficiency Testing for Mohs Micrographic Surgery (MMS)" states that three Mohs cases will be randomly selected biannually for review. The review revealed that the laboratory failed to perform peer slide review for calendar year 2024 and only performed one peer slide review for 2023 on 12/17/2023. The OM confirmed in an interview on 4/25/2025 at 12:52 P.M. that the twice annual peer slide review was not performed twice annually for calendar year 2024 and only performed once for calendar year 2023. The laboratory performs 120 Mohs cases annually. 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 --