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 record review and staff interview, the laboratory failed to verify the accuracy bi-annually for MOHS micrographic surgery procedures in the subspecialty of histopathology. Findings include: 1. Record review of the laboratory's 2018 and 2019 proficiency testing and verification records on 1/7/2020 revealed the laboratory did not have biannual verification for accuracy of histopathology interpretation for 1 of 1 MOHS personnel. 2. Phone interview with the technical supervisor on 1/7/2020 at 9:55 AM confirmed the above finding and personnel were not assessed. 3. The laboratory performs 95 MOHS procedures annually. 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 --