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 the surveyor's review of the laboratory's records for evaluation of proficiency testing performance and an interview with laboratory personnel (LP) on 5 /19/2022 between 12:30 p.m. and 2:30 p.m., it was determined that the laboratory failed to at least twice annually, document their quality assurance/proficiency peer review testing for the year 2021. Findings include: 1. On 5/19/2022, an inspection was conducted between 12:30 p.m. and 2:30 p.m. 2. During a review of the laboratory quality/peer review documentation, it was noted at approximately 1:00 p.m. that the laboratory failed to document peer proficiency testing for MOHS Histopathology in 2021. 3. The LP recognized that this documentation was missing. 4. MD peer review documentation was present for 2022. 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 --