Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 013401	(X3) Date Survey Completed 03/01/2023
Name of Provider or Supplier Lawrence Rural Health Clinic-Courtland	Street Address, City, State 350 Tennessee Street P O Box 320, Courtland, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000	A recertification survey was conducted 2/28/23 to 3/01/23 at Lawrence Rural Health Clinic-Courtland. The clinic was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.
J0000	A recertification survey was conducted at Lawrence Rural Health Clinic-Courtland 2/28/23 to 3/1/23. Standard level deficiencies were cited and will require a plan of correction.
J0043	PHYSICAL PLANT AND ENVIRONMENT The clinic . . . has a preventive maintenance program to ensure that: 491.6(b)(2) Drugs and biologicals are appropriately stored; and This STANDARD is not met as evidenced by: Based on observations, clinic policy, and interviews with staff, it was determined the clinic failed to ensure that no expired drugs, biologicals, and supplies were available for patient use. Findings include: Clinic Policy: Sampling of Medications by Health Clinics Reference Number: CNC0015 Effective Date: 02/08 Policy: ...All sample and medications will be checked monthly for out of date medications... ...Any expired medications are disposed of in the correct disposal manner as designated by the pharmacists... 1. A tour of the clinic was conducted on 2/28/23 at 9:15 AM with Employee Identifier (EI) #2, Rural Health Clinic Coordinator. The following medications/supplies available for patient use were observed as expired: a. One Tegaderm film with an expiration date of 11/19/21. b. One Chloraprep one step with an expiration date of 06/21. c. One BD insyte 20 gauge (g) Intravenous (IV) catheter with an expiration date of 11/30/21. d. One BD insyte 22 g IV catheter with an expiration date of 8/31/21. e. One Saniwipes gray top tub with an expiration date of 12/22. f. Two gallon sized zip-lock bags filled with ten cc (cubic centimeter) syringes with expiration date 11/30/20. g. One Bard urethral catheterization tray with expiration date 10/30/21. EI # 2 confirmed during the tour that staff failed to ensure expired supplies/medications were not available for patient use. 41624
J0124	PROVISION OF SERVICES 491.9(b) Patient care policies. (3) The policies include: (i) A description of the services the clinic . . . furnishes directly and those furnished through agreement or arrangement. (ii) Guidelines for the medical management of health problems which include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the clinic . . . This STANDARD is not met as evidenced by: Based on review of the clinic policy and procedure manual and interview, it was determined the clinic's written policies and procedures failed to include a policy for medical management guidelines of frequently encountered health conditions, the actions non-physician practitioners/NP (Nurse Practitioner) were permitted to initiate and implement, and circumstances that require consultation and referral. This had the potential to negatively affect all patients treated at the clinic. Findings include: 1. On 3/1/23 at 2:06 PM, the surveyor reviewed the clinic's policies and procedures and requested to review the clinic's policy for medical management guidelines for frequently encountered health conditions treated at the clinic. On 3/1/23 at 2:06 PM, Employee Identifier (EI) # 1, Practice Manager Rural Health Clinics, confirmed there was no written policy that included medical management guidelines/protocols for the nurse practitioners.
J0135	PROVISION OF SERVICES 491.9(a) Basic requirements: (3) The laboratory requirements in paragraph (c)(2) of this section apply to RHCs, . . . 491.9(c) Direct services (2) Laboratory. These requirements apply to RHCs . . . . The RHC provides laboratory services in accordance with part 493 of this chapter, which implements the provisions of section 353 of the Public Health Service Act. The RHC provides basic laboratory services essential to the immediate diagnosis and treatment of the patient, including: (i) Chemical examinations of urine by stick or tablet method or both (including urine ketones); (ii) Hemoglobin or hematocrit; (iii) Blood glucose; (iv) Examination of stool specimens for occult blood; (v) Pregnancy tests; and (vi) Primary culturing for transmittal to a certified laboratory. This STANDARD is not met as evidenced by: Based on observation, clinic policy, and interview with staff, it was determined the clinic failed to provide laboratory services to include on-site hematocrit and/or hemaglobin testing. This had the potential to affect all patients served by the clinic. Findings include: Clinic Policy: Lawrence Rural Health Clinics Policy Number: None Review Date: 11/2022 Provision of Services: ...G. Laboratory and X-Ray Services 1. The ability to perform on-site basic laboratory services including hematocrit,...will be facilitated by the clinic staff.... 1. A tour of the clinic was conducted on 2/28/23 at 9:15 AM which included the clinic's laboratory (lab) station. During the tour, no equipment or supplies were observed to be able to perform hematocrit and/or hemaglobin testing as required on-site. Employee Identifier (EI) # 2, Clinical Coordinator, was present during the tour of the lab. The surveyor asked EI # 2 if the clinic performed hematocrit or hemaglobin testing on-site? EI # 2 stated there was no equipment available to perform hematocrit or hemaglobin testing. The clinic failed to provide all on-site lab tests as required for a rural health clinic, including hematocrit and/or hemaglobin. EI # 2 confirmed at 10:10 AM on 2/28/23 the clinic did not perform hematocrit or hemoglobin testing on-site.