Summary:
Summary Statement of Deficiencies D5787 TEST RECORDS CFR(s): 493.1283(a) The laboratory must maintain an information or record system that includes the following: (a)(1) The positive identification of the specimen. (a)(2) The date and time of specimen receipt into the laboratory. (a)(3) The condition and disposition of specimens that do not meet the laboratory's criteria for specimen acceptability. (a)(4) The records and dates of all specimen testing, including the identity of the personnel who performed the test(s). This STANDARD is not met as evidenced by: Based on surveyor review of the Mohs Log Sheet (MLS), Test Records (TR) and interview with the Office Manager (OM), the laboratory failed to maintain an accurate information system for Histopathology tests from 8/6/24 to 8/21/24. The findings include: 1. A review of the MLS revealed: a) Case # NF24.253 had 2 stages documented on the MLS but had 3 stages documented on the MOHS map and final report. b) Case #NF24.233 only had 6 slides documented, but there were 8 slides total for this case. 2. The OM confirmed at 1:30 pm on 8/21/24 the laboratory failed to maintain an accurate information system. 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 --