Summary:
Summary Statement of Deficiencies D3011 FACILITIES CFR(s): 493.1101(d) Safety procedures must be established, accessible, and observed to ensure protection from physical, chemical, biochemical, and electrical hazards, and biohazardous materials. This STANDARD is not met as evidenced by: Based on surveyor observation, record review and staff interview with the Mohs Clinical Resource Manager (MCRM) and the Practice Manager (PM) the laboratory failed to verify the function of the eyewash station on a weekly basis as no documentation or other evidence demonstrated that the required checks were performed. Findings include: 1. Surveyor observation on 7/28/2026 at 11:45 AM of the laboratory potassium hydroxide (KOH)/wetmount area identified one plumbed eyewash station. 2. Record review on 7/28/2026 of the laboratory's 2025 and 2026 "Eyewash Weekly Inspection Logs" located in the KOH/wet mount testing area revealed the following: a. The laboratory failed to perform weekly function checks of the eyewash station during 13 of 37 weeks after assuming responsibility for KOH and wet mount testing in April 2025. b. The laboratory failed to perform weekly function checks of the eyewash station during 6 of 23 weeks from January 2026 through the date of review. c. The laboratory did not document