Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 013429	(X3) Date Survey Completed 02/07/2018
Name of Provider or Supplier Grove Hill Primary Care	Street Address, City, State 297 South Jackson Street, Grove Hill, 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 on 2/7/18 and the facility was found to be in compliance with the Condition of Participation, Appendix Z, Emergency Preparedness Requirements.
J0000	A recertification survey was conducted on 2/7/18 at Coffeeville Medical Clinic and standard level deficiencies were cited.
J0021	MAINTENANCE CFR(s): 491.6(b) The clinic ... has a preventive maintenance program to ensure that: This STANDARD is not met as evidenced by: Based on observations and interviews with the staff it was determined the facility failed to ensure the equipment within the facility had preventive maintance conducted at least annually by qualified personnel and all equipment was tagged with the date of the inspection and a record kept of each inspection. This had the potential to negatively affect all patients served by the facility. Findings include: A tour of the facility was conducted on 2/7/18 at 8:45 AM with Employee Identifier (EI) # 2, Nurse Practitioner. During the tour, the laboratory (lab) area was reviewed and on the counter in the lab area was a machine and when the surveyor asked EI # 2 what the machine was EI # 2 responded by saying it is the Hematocrit machine. The surveyor observed the preventive maintance sticker with a date due of 6/14 and no other sticker was present on the machine. EI # 2 confirmed the date on the sticker. Observation of exam room # 1 revealed no preventive maintance sticker on the exam room table. Review of exam room # 3 revealed an Intravenous (IV) pole, the exam light and the exam table did not have preventive maintance stickers. Review of the Triage room revealed 1 set of baby scales and 2 adult stand up scales all lacking a preventive maintance sticker. An interview was conducted on 2/7/18 at 1:00 PM with EI # 1, Office Manager and EI # 2 who confirmed the above mentioned findings.
J0023	MAINTENANCE CFR(s): 491.6(b)(2) Drugs and biologicals are appropriately stored; and This STANDARD is not met as evidenced by: Based on observations, policy and procedure manual documentation and interviews with the staff it was determined the facility failed to ensure all medications and supplies available for patient use were not expired and were stored safely. This had the potential to negatively affect all patients served by the facility. Findings include: Policy: Out of Date Drugs/Medical Supplies in Examination/Procedure Rooms Origination Date: 10/16/17 Policy: It is the policy of Coffeeville Medical Clinic to promote the safety of drugs and medical supplies dispensed or stored in the examination/procedure rooms by eliminating discontinued or expired drugs and medical supplies on a monthly basis. Procedure: ...On the last working day of each month, a nurse shall inspect all drugs/medical supplies in all of the examination/procedure rooms and document the inspection on the Expired Drug Log and Expired Medical Supply Log... All expired drugs and medical supplies will be disposed of per clinic policy and new supplies replaced immediately. All open containers/ drugs will be labeled with the date opened and disposed of 30 days from the date container/drug is labeled. Policy: Review of Pharmacy Purpose: To provide safe storage of drugs and biological's Policy: A review of drugs and biological's stored at the health clinic is conducted at least monthly. Review of the monthly checklist, as well as the supply will be conducted annually. The annual review will also examine: Types of medications stored at the clinic Expiration dates of drugs and biological's and proper disposal of these drugs Prior to expiration of the drug, the stock should be rotated to use the oldest dates first. Protection / security of over the counter and prescription medications from unauthorized individuals... On 2/7/18 at 9:00 AM a tour of the facility was conducted. During the tour the Laboratory area was observed. The surveyor found 26 packs of HCG ( Human Chorionic Ganadotropin) Serum / Urine QuickVue with an expiration date of 1/13/18 and 1 Hemoccult developer bottle with an expiration date of 11/2007. The supply room/medication room was observed during the tour. In the supply closet was a box of Sterile Latex Gloves size 7.5 with a use before date of 12/2014. Observation of the refrigerator in the supply room revealed 1 Humalog Kwik Pen 100 units with an expiration date of 12/17. In the supply room are 2 closets each containing medications for use within the clinic. In the first medication closet was 1- 500 ml (milliter) bottle of Normal Saline with an open date of 11/8/17 which is past the 30 days as mentioned in the facility policy. In the second medication closet, the following was observed: 1- 1000 ml bag of Lactated Ringers with an expiration date of January 2018, 5 boxes of Tradjenta each box containing 7 tablets 5 mg (milligrams) per tablet with an expiration date of 1/18. Observation of Exam Room # 2 revealed the following expired supplies: 2 - Female Cleaning Swabs with expiration dates of 12/17 1 - Female Cleaning Swab with the expiration date of 3/17. Observation of Exam Room # 3 revealed a crash cart. Review of the crash cart medications revealed the following expired medications: 2 - Adenocardo bottles expired 12/1/17 5 - Epinephrine 1:1000 (1 mg / ml) expired 1/18. An interview was conducted on 2/7/18 at 1:00 PM with EI # 1, Office Manager and EI # 2 who confirmed the above mentioned findings.
J0070	RECORDS SYSTEM CFR(s): 491.10(a)(3) For each patient receiving health care services, the clinic ... maintains a record that includes, as applicable: (i) Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; (ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings; (iii) All physician's orders, reports of treatments and medications and other pertinent information necessary to monitor the patient's progress; (iv) Signatures of the physician or other health care professional. This STANDARD is not met as evidenced by: Based on review of medical records (MR's) and interviews with the staff it was determined the facility failed to ensure each patient's MR contained a signed consent for treatment form. This affected 4 of 10 MR's reviewed and did affect MR # 1, MR # 4, MR # 6 and MR # 7 and had the potential to negatively affect all patients served by the facility. Findings include: Review of 10 MR's revealed the facility failed to ensure all patients signed a consent for treatment form prior to being seen by the physician or the nurse practitioner. Review of MR # 1, MR # 4, MR # 6 and MR #7 revealed no signed consent forms within the patient's medical record. An interview was conducted on 2/7/18 with Employee Identifier (EI) # 1, Office Manage, who confirmed the above mentioned findings.