Summary:
Summary Statement of Deficiencies D3043 RETENTION REQUIREMENTS CFR(s): 493.1105(a)(7) (a)(7) Slide, block, and tissue retention-- (a)(7)(i) Slides. (a)(7)(i)(A) Retain cytology slide preparations for at least 5 years from the date of examination (see 493.1274(f) for proficiency testing exception). (a)(7)(i)(B) Retain histopathology slides for at least 10 years from the date of examination. (a)(7)(ii) Blocks. Retain pathology specimen blocks for at least 2 years from the date of examination. (a)(7)(iii) Tissue. Preserve remnants of tissue for pathology examination until a diagnosis is made on the specimen. This STANDARD is not met as evidenced by: Based on record review and interview with the Mohs Technician (MT), the laboratory failed to retain 1 (patient #5) of 9 histopathology slides reviewed. Findings include: 1. A request was made to review patient test reports, Mohs maps, pathology reports, and histopathology slides for nine patients from the testing period of September 2023 through July 2025. The MT provided all requested information except for the histopathology slide for patient #5, dated 08/02/2024. 2. An interview on 08/15/2025 at 4:27 pm with the MT confirmed that the slide for patient #5 could not be located. 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 --