[Histonet] FW: FW: Follow Up: Joint Commission Lab Survey CorrectiveAction Plan West MOHS

Ingles Claire CIngles <@t> uwhealth.org
Wed Dec 16 13:47:35 CST 2009

OK Guys, here's another JCAHO/CLIA controversy. Has anyone (Mostly MOHS labs) been sited for this? Currently we only save tissue specimens 24 hours in case the Dr. decides to send some to path after the fact. (don't get me going on morphology quality). Does anyone have a clear definition of "gross tissue specimens" It's not like we measure this stuff before freezing.
Thanks for your well educated guesses


West MOHS Clinic was cited for a deficiency regarding maintenance and storage of tissue during the Joint Commission Lab Survey. 

According to standard QC.2.120, EP 2:  Microscopic slides, paraffin blocks, bone marrow aspirates, needle biopsy specimens, and gross tissue specimens are stored for required times as defined by organization policy, law, and regulation.  Microscopic slides, including stained slides, are retained for at least 10 years.  Paraffin blocks are stored for a minimum of two years from the date of examination.  Gross tissue specimens are retained for at least seven days after required microscopic sections are examined and reports reviewed and signed.  State law and regulation requirements are for longer times (See Appendix XX for additional specific retention times.)

The surveyor observed in his report that "biopsy tissue was frozen for section, slides prepared and then the tissue was discarded.  Gross tissue specimens must be retained for seven days after the microscopic sections are examined and reports reviewed and signed."

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