Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 013429	(X3) Date Survey Completed 12/10/2025
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 at Grove Hill Primary Care 12/9/25 to 12/10/25. The facility was found to be in substantial compliance with the Emergency Preparedness requirements at 491.12, Conditions for Certification for Rural Health Clinics.
J0000	A recertification survey was conducted at Grove Hill Primary Care 12/09/25 to 12/10/25. Standard level deficiencies were cited which will require a plan of correction.
J0041	PHYSICAL PLANT AND ENVIRONMENT 491.6(a) Construction: The clinic and the center is constructed, arranged, and maintained to insure access to and safety of patients, and provides adequate space for the provision of direct services. This STANDARD is not met as evidenced by: Based on observations and interview with staff, it was determined the clinic failed to ensure all electrical outlets had safety coverings in areas providing care to pediatric patients to ensure patient and staff safety. This had the potential to affect all patients treated at this clinic. Findings include: Clinic Policy: None Provided A tour of the clinic was conducted on 12/9/2025 at 10:20 AM with Employee Identifier (EI) # 2, Office Manager, and the following was observed: Three electrical outlets in Exam room # 2 had no safety covers. Six electrical outlets in Exam room # 3 had no safety covers. During the tour, EI # 2 confirmed the clinic failed to ensure safety coverings were installed on all electrical outlets in areas providing care to pediatric patients to ensure patient and staff safety.
J0042	PHYSICAL PLANT AND ENVIRONMENT 491.6(b) Maintenance: The clinic . . . has a preventive maintenance program to ensure that: (1) All essential mechanical, electrical and patient-care equipment is maintained in safe operating condition; This STANDARD is not met as evidenced by: Based on observations, clinic policy, interviews with staff, and manufacturer's directions for use (MDFU) it was determined the clinic failed to ensure preventive maintenance (PM) was conducted on all electrical equipment in the clinic to ensure patient and staff safety. This had the potential to affect all patients treated at this clinic. Findings include: Clinic Policy: PREVENTIVE AND REQUIRED MAINTENANCE Policy number: 210.0 Date: 10/22/2020 Policy Purpose: The purpose of this policy is to outline the procedures related to preventive and/or required maintenance. Policy Body: Preventive Maintenance... 2. Biomedical and Equipment Used to Deliver Patient Care a. The clinic shall maintain a service agreement or have an arrangement to routinely inspect and maintain equipment related to direct patient care, diagnostic procedures, or therapeutic procedures. The agreement or arrangement shall provide for: i. An initial inspection of all bio-medical equipment shall be made in preparation for initial RHC certification. ii. Regularly scheduled inspections shall be conducted at subsequent intervals which shall not exceed 12 months from the initial inspections (at least annually). Contour Next blood glucose Control Solution Testing, and Quality Control MDFU ... You should perform a control test when: Using the meter for the first time, you open a new bottle or package of test strips, you think your meter may not be working correctly, or if you have repeated, unexpected blood glucose results. 1. A tour of the clinic was conducted on 12/9/2025 at 09:30 AM with Employee Identifier (EI) # 2. The following deficiencies were observed: A Welch Allyn (brand) Otoscope with a PM label dated 02/2020 and electric exam table with no PM label were observed in Exam room # 1. A Welch Allyn Otoscope with a PM label dated 02/2020, an electric exam table and floor base exam light with no PM labels were observed in Exam room # 2. A Welch Allyn Otoscope and electric exam table with no PM labels were observed in Exam room # 3. A weighing scale with an unreadable PM label and a Welch Allyn Otoscope with a PM label dated 07/2021 were observed in the triage area. A portable suction machine with no PM label was observed on top of the crash cart in the hallway. A small refrigerator used for medication storage with a PM label dated 3/2019 was observed in the Medication room. No equipment maintenance log or documentation of equipment management was provided. During the tour EI # 2, Office Manager, confirmed the clinic failed to ensure PM was performed annually per policy on all patient care electrical equipment to ensure patient and staff safety. 2. A tour of the reception area was conducted on 12/9/2025 at 1:00 PM and the following deficiencies were observed: A Contour Next (brand) blood glucose meter was observed in the reception area for use in patient care. There was no documentation of quality control testing for the blood glucose meter. EI # 2, Office Manager confirmed there was no documentation of quality control testing for the blood glucose meter to ensure patient safety per company policy.
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 interview, it was determined the clinic failed to ensure expired medication, laboratory (lab) controls, and patient care supplies were not available for patient use to ensure patient safety. Findings include: Clinic Policy: STORAGE, HANDLING & ADMINISTRATION OF DRUGS, BIOLOGICALS, AND PHARMACEUTICALS Policy number: 220.0 Date: 3/10/2025 Policy Purpose: The purpose of this policy is to outline the procedures related to the storage and handling of drugs, biological and pharmaceuticals. Policy Body: Storage, Handling and Administration of Drugs, Biologicals, and Pharmaceuticals 1. General Storage and Handling Guidelines... 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. 1. A tour of the medication storage/ preparation room was conducted on 12/9/2025 at 11:00 AM with Employee Identifier (EI) # 2, Office Manager. The following expired medications were observed in the medication room: a. Six packs of Slynd 28 tablets blister pack with an expiration (exp) date of 11/2025. b. One Vitafol Ultra Unit dose pack (3 softgel caps) with an exp date of 6/2025. c. Forty packs of Imvexxy 10 micrograms (mcg) vaginal inserts with an exp date of 10/2025. d. Seven Clonidine 0.1 milligram (mg) tablet blister packs with an exp date of 10/2025. e. One opened multi-dose vial of Delestrogen 100 mg/5 milliliter (ml) with exp date of 1/2026 and no opened date/use by date indicated. f. One opened multi-dose vial of Testosterone Cypionate 200 (mg/ml) with exp date of 5/2027 and no opened date/use by date indicated. 2. A tour of the medication storage room # 2 was conducted on 12/9/2025 @ 11:30 AM with EI # 2. The following expired medications were observed in the medication storage room: a. Six vials of QC Hemoglobin Control/multi level with an exp date of 8/31/2025. b. One opened vial of Admelog 100 units/ml with no use by date indicated. 3. A tour of the reception area was conducted on 12/9/2025 at 1:00 PM and the following deficiencies were observed: One container of low glucose monitoring solution with an exp date of 7/23/2025 was observed. One container of high glucose monitoring solution with an exp date of 7/23/2025 was observed. During the tour EI # 2 confirmed the clinic failed to ensure that exp pharmaceuticals were unavailable for patient use per clinic policy to ensure patient safety.
J0044	PHYSICAL PLANT AND ENVIRONMENT The clinic . . . has a preventive maintenance program to ensure that: 491.6(b)(3) The premises are clean and orderly. This STANDARD is not met as evidenced by: Based on observation and interview, it was determined the clinic failed to ensure safe use of specialized suture scissors and forceps to prevent the potential spread of infectious diseases. This deficient practice had a potential to negatively affect all staff and patients served by the facility. Findings include: Policy: DISINFECTION AND STERILIZATION POLICY Policy number: 238.0 Date: 10/22/2020 Policy Purpose: The purposes of this policy are to clearly outline the procedures which shall be taken to disinfect and sterilize equipment, supplies, instruments, and surfaces. Policy Body: Disinfection and Sterilization... 3. Pretreating or Preparing Items for Sterilization a. Dirty items shall be transported to a designated dirty area within the clinic from the original patient care area. Care shall be taken to prevent contamination during transport... 8. Reusable DME and Supplies: ...supplies which may be reused by multiple patients shall be labeled as either clean or dirty to alert staff of the condition of the item. A tour of the medication and supply storage area was conducted on 12/9/2025 at 11:30 AM with Employee Identifier (EI) # 4, Medical Assistant. The following deficient practice was observed: Fifteen unpackaged suture scissors, three unpackaged forceps and one sealed package containing a suture scissor and forceps all stored in a plastic container together were observed on the countertop. An interview was conducted on 12/9/2025 at 11:35 with EI # 4, who confirmed the scissors and forceps in the sealed package were sterile and ready for patient use. She/he further confirmed the unpackaged scissors and forceps had been pre-cleaned and were ready to be sent to autoclave and were not labeled and stored per clinic policy to assure staff and patient safety.
J0125	PROVISION OF SERVICES 491.9(b) Patient care policies. (3) The policies include: (iii) Rules for the storage, handling, and administration of drugs and biologicals. This STANDARD is not met as evidenced by: Based on observations, clinic policy, medical record (MR) review, and interviews with staff, it was determined the clinic failed to ensure the medical provider's order for medication administration was followed. This deficient practice affected one of two patients in observations of medication administration including MR # 1 and had the potential to affect all patients treated at this clinic. Findings include: Clinic Policy: Storage, Handling & Administration of Drugs, Biologicals, and Pharmaceuticals Policy Number: 220.0 Revised: 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... 3. Administration of Drugs: a. Use of Patient Identifiers: The clinic shall use acceptable patient identifiers to confirm that the patient name, the order, and the selected drug are in agreement prior to administration... b. The Six Rights: All staff who are responsible for medication administration shall follow the "Six Rights" to ensure accurate administration of drugs... 1. MR # 1 presented to the clinic on 12/9/25 at 8:22 AM with complaints of nausea and diarrhea. Review of the Clinic Provider Note, Ordered Medications, dated 12/9/25 at 9:33 AM revealed medication orders for Ondansetron Hydrochloride (HCL) 2 milligrams (mg) to be administered intramuscular (IM). An observation of medication administration by Employee Identifier (EI) # 4, Medical Assistant, was conducted on 12/9/25 at 9:35 AM. EI # 4 removed one vial of Ondansetron HCL 2 mg/milliters (ml), 2 ml vial from the medicine cabinet. EI # 4 withdrew 2 ml from the Ondansetron vial, entered MR # 1's room, and administered the Ondansetron HCL 2 ml (4 mg) IM to MR # 1. EI # 4 failed to follow the provider's order for the dosage of the medication. An interview was conducted on 12/9/25 at 1:50 PM with EI # 4. EI # 4 was asked what was the dosage of the Ondansetron withdrawn and administered to PI # 1. EI # 4 responded, "The whole vial, 2 ml." An interview was conducted on 12/10/25 at 12:15 PM with EI # 1, Nurse Manager, who confirmed the staff failed to confirm the medication dosage and administer the correct medication dosage as ordered.