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 a review of Quality Assessment (QA) records and an interview with Mohs Tech #1, the laboratory failed to verify the accuracy of Histopathology performed on frozen sections collected during Mohs Surgery at least twice annually. This was noted for two out of two possible events in 2023. The findings include: 1. A review of Quality Assessment records revealed no evidence of the Laboratory Director verifying the accuracy of Histopathology slides with another provider since the date of the last survey, 8/3/2022. One QA event was pending for 2024. 2. During an interview on 4/26 /2024 at 11:00 AM, Mohs Tech #1 confirmed no other QA records were available for review at the time of survey. 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 --