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 interview with the Office Manager, the laboratory failed to verify the accuracy of the reading and interpretation of the Hematoxylin and Eosin (H&E) stain twice annually in 2017 - 2018 for 3 out 8 testing personnel ( #A, #G, and #H) by peer review. Findings include: 1. Review of the laboratory's records revealed documentation of one peer review for testing personnel #A for 2017 and twice annual peer reviews were absent for testing personnel #G and #H for 2017 -2018. 2. Interview on 12/04/18 at 11:30 AM, the Office Manager confirmed the lack of peer reviews for testing personnel #A, #G, and #H. 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 --