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 six (6) randomly selected patients records from 11/08/2017 to 05 /02/2019, Mohs surgical procedure documents, an interview with the laboratory director and lack of documentation for verification of the accuracy of the test or procedure, it was determined that the laboratory failed to at least twice a year verify the accuracy of the Mohs surgical procedure performed and reported for 2017 and 2018. The findings included: a. The laboratory's policy entitled "Proficiency Testing Mohs Micrographic Surgery" under Procedure: Each 6-12 months one case will be randomly selected for review by a Pathologist/Dermatologist/MOHS surgeon. On 06 /19/2019 (survey date) the laboratory was unable to retrieve documentation of twice a year verification of accuracy for Mohs procedures performed and reported for the years 2017 and 2018. b. The laboratory director confirmed on 06/19/2019 13:00 that no Mohs proficiency testing (peer review) was performed for the years 2017 and 2018. 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 --