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 policy and procedure review, and an interview with the Technical Supervisor (TS), the laboratory failed to blindly verify the accuracy of the Mohs procedure, not listed in Subpart I, at least twice annually. Findings Include: 1. Review of the laboratory's policy and procedure found a document titled "PROFICIENCY TESTING MOHS MICROGRAPHIC SURGERY SKIN SPECIMENS" containing the following statement: "Semi-annually, the tech or Risk Manager will send two cases containing the original slides, label it with only surgical case number, and send it our for a microscopic examination by a Board Certified Pathologist." 2. An interview with the TS confirmed no Mohs slides were sent for verification of accuracy in 2016. The interview occurred on 02/21/2018. 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 --