Summary:
Summary Statement of Deficiencies D5891 POSTANALYTIC SYSTEMS QUALITY ASSESSMENT CFR(s): 493.1299(a) The laboratory must establish and follow written policies and procedures for an ongoing mechanism to monitor, assess and, when indicated, correct problems identified in the postanalytic systems specified in 493.1291. This STANDARD is not met as evidenced by: Based on review of a Frozen Biopsy test report and interview with the facility personnel, the laboratory failed to include the gross description on the pathology test report. Findings include: 1. Review of the pathology test report for specimen# FS002- 2019 failed to include the gross description. 2. It is the policy of the laboratory to report the frozen biopsy test results in the patient's electronic record. 3. The facility personnel acknowledged that the frozen biopsy test report indicated above failed to include the gross description. 4. The laboratory performed approximately 2 frozen biopsies during 2019 to the date of the survey conducted on October 8, 2019. 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 --