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 quality Mohs frozen section peer review quality assessment records reviewed and interview with staff the laboratory failed to verify the accuracy for the presence or absence of tumor cells at least twice annually in 1 of 2 years of testing reviewed (2019). The laboratory performed approximately 263 frozen sections per year. Findings include: 1. Frozen Section peer review for test accuracy failed to include two events of test accuracy in 2019. 2. In an interivew with staff on 01/22 /2020 at approximately 11:30 A.M. staff confirmed they failed to document they checked histopathology frozen section testing twice in 2019. 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 --