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 review of twice yearly verification documentation, review of procedures, and interview with processing personnel #1, the laboratory failed to verify accuracy of the for MOHS frozen section quality assurance slides at least twice annually from May 2022 and to date July 26, 2023. Findings: 1. Review of MOHS verification of accuracy revealed the laboratory failed to verify the accuracy of MOHS slides two times per year from May 2022 to date July 26, 2023. 2. Review of MOHS Frozen Section Quality Assurance - Random Retrospective Slide Review policy states "One percent of MOHS cases that have been previously signed out will be selected for review by the lab supervisor on the first business day of January and July. 3. Interview with processing personnel #1 on July 26, 2023 at 3:00 PM confirmed the laboratory failed to verify accuracy twice annually for MOHS frozen section quality assurance slides. 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 --