Summary:
Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at Virginia Dermatology and Skin Cancer Center on January 15, 2020 by the Virginia Department of Health's Office of Licensure and Certification. The laboratory was surveyed under 42 CFR part 493 CLIA Requirements. The specific deficiency cited is as follows: 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 policies and procedures, proficiency testing (PT) records, and an interview, the laboratory failed to perform split sample comparison evaluations twice annually for MOHS micrographic skin specimen testing in calendar year 2019. Findings include: 1. Review of the laboratory's procedure manual revealed a PT policy for MOHS micrographic surgery skin specimens (titled: "Physician Proficiency Testing"). The policy stated "A review of the test results on each MOHS provider will be performed bi-annually. The twice annual review is to ensure the accuracy of each test result and the quality of slides the laboratory is producing". 2. Review of the laboratory's PT documentation from January 2018 to the date of survey revealed one (1) MOHS PT was performed and evaluated in calendar year 2019 (recorded on 09/16 /19). The inspector requested documentation of additional split sample PT studies in 2019. No additional documentation was available for review. 3. In an exit interview with the practice manager and histotechnologist at approximately 2:00 PM, the above listed findings were confirmed. 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 --