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 the laboratory's peer review records, and interview with testing personnel #2 (TP), the laboratory failed to ensure that the verification of accuracy for MOHS micrographic surgery slide examinations were performed at least twice annually in 2021. Findings Include: 1. On the day of the survey, 02/21/2022 at 10:14 am, the laboratory could not provide documentation that the verification of accuracy for MOHS micrographic surgery slide examinations stained using hematoxylin and eosin (H&E) were performed at least twice annually in 2021. 2. The laboratory performed 800 MOHS micrographic surgery slide examinations in 2021. 3. TP #2 confirmed the findings above on 02/21/2023 around 11:00 am. 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 --