| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 013424 | (X3) Date Survey Completed 09/11/2025 |
| Name of Provider or Supplier Regional Medical Center Clinics | Street Address, City, State 125 Church Street, Georgiana, 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 at Regional Medical Center Clinics on 9/10/25 to 9/11/25. Regional Medical Center Clinics was found to be in substantial compliance for Emergency Preparedness. |
| J0000 | A recertification survey was conducted at Regional Medical Center Clinics from 9/10/25 to 9/11/25. Standard level deficiences 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 observation, clinic policy, and interview with staff, it was determined the clinic failed to ensure multi-dose vials (MDV) were dated when opened or had an expiration date, and expired drugs were not available for patient use. This had the potential to negatively affect all patients served by the clinic. Findings include: Policy: Storage, Handling & Administration of Drugs, Biologicals, and Pharmaceuticals Policy Number: 220.0 Revision Date: 3/10/25 Policy Purpose: The purpose of this policy is to outline the procedures related to the storage and handling of drugs, biological and pharmaceuticals. Policy Statement: It is the intention of the Clinic to ensure that drugs, biological, and pharmaceuticals are stored, handled and administered in a manner that safeguards the products and control usage. ...o. All drugs and biologicals shall be inventoried for expiration dates (beyond use dates) on a monthly basis by a designated staff member, usually a member of the nursing staff or medical assistant. The Clinic Manager shall periodically spot check the supply area to ensure compliance. A tour of the clinic was conducted on 9/10/25 at 09:03 AM. The following medications were expired and available for patient use: One Lincomycin Injection 3,000 milligrams (mg) per 10 milliliters (ml) Intramuscular, MDV, with an expiration date of 4/16/25. Three Diphenhydramine Hydrochloride Injection 50 mg/ml one ml single dose with an expiration date of 7/25. Twenty-three Diphenhydramine Hydrochloride Injection 50 mg/ml 1 ml single dose with an expiration date of 8/25. An interview was conducted on 9/11/25 at 2:16 PM with Employee Identifier # 1, Physician Practice Director, who confirmed the clinic failed to ensure expired medications were not available for patient use. |