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 surveyor review of the Biannual Assessment (BA) records and interview with the Mohs Technician, the laboratory failed to verify the accuracy and reliability of Mohs testing twice annually from 9/12/22 to the date of the survey. The findings include: 1. There was no documented evidence Slide # R23-45 was reviewed for the BA performed on 3/11/23. 2. The Reviewing Pathologist and the Referring Pathologist failed to sign the BA for slides R23-44 and R23-45 performed on 3/11/23 and slides R22-157 and R22-160 performed on 9/12/22. 3. The Mohs Technician confirmed on 11/22/23 at 1:30 pm that the laboratory failed to verify the accuracy and reliability of Mohs testing. 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 --