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 laboratory records, the lack of records, and interview with an administrator, it was determined the laboratory failed to verify the accuracy of Mohs procedures performed in 2024. Findings included: 1. Mohs records for 2024 documented procedures performed by Testing Person-MM. 2. For 3 out of 3 records reviewed for 2024, the laboratory had no records of peer review of any Mohs slides, as follows: Date Mohs Case -------------------------------- 10/30/24 24E- M278 11/27/24 24E- M298 12/11/24 24E- M306 3. An administrator affirmed (7/07/26 at 12:00 PM) the testing person in 2024, and that no records of peer review for 2024 could be found. . 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 --