Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 013430	(X3) Date Survey Completed 04/06/2023
Name of Provider or Supplier Hill Hospital Physicians Clinic	Street Address, City, State 724 Derby Drive, York, 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	Based on the recertification survey conducted from 4/5/23 to 4/6/23, Hill Hospital Physicians Clinic was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.
J0000	A recertification survey was conducted from 4/5/23 to 4/6/23 at Hill Hospital Physicians Clinic, standard level deficiencies were cited and will require an acceptable 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, clinic policy, 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. This deficient practice had a potential to negatively affect all pediatric patients served by the facility. Findings include: Clinic policy: Hill Hospital Physicians Clinic Organizational Structure Policy number: none provided Reviewed: 1/10/23 ...The Clinic is ... constructed, arranged and maintained to ensure ... safety of patients... A tour of the clinic was conducted on 4/5/23 at 12:15 PM with Employee Identifier (EI) # 1, Clinic Manager. The following electrical outlets failed to have safety coverings: 1. In the lobby area four electrical outlets were without safety coverings. 2. In exam room # 2, two electrical outlets were without safety coverings. 3. In exam room # 3, one electrical outlet was without a safety covering. In an interview conducted on 4/6/23 at 1:30 PM, EI # 1 confirmed the clinic failed to ensure all of the electrical outlets were covered for safety of pediatric patients.
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, and interview with staff, it was determined the clinic failed to ensure preventive maintenance (PM) was conducted on all electrical equipment in the clinic to ensure safety. This deficient practice had the potential to affect all patients treated at this clinic. Findings include: Clinic policy: Hill Hospital Physicians Clinic Organizational Structure Policy number: none provided Reviewed: 1/10/23 ... 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... A tour of the clinic was conducted on 4/5/23 at 12:15 PM with Employee Identifier # 1, Clinic Manager. In Exam Room # 1 an electric space heater was located, no PM sticker was on the unit and no documentation of inspection was provided. In an interview conducted on 4/6/23 at 1:30 PM, EI # 1 confirmed the clinic failed to ensure the electric space heater had been inspected for safety by the maintenance department. EI # 1 further stated the heater had been removed from the clinic since the tour on 4/5/23.
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 with staff, it was determined the clinic failed to ensure no expired medications or supplies were available for patient use. This deficient practice had the potential to affect all patients treated at this clinic. Findings include: Clinic policy: Medication Area Inspections Policy number: none provided Policy update: 1/25/15 Re: Multi dose vials Multi dose vials will be dated immediately upon opening. The multi dose vial will be discarded on the 28th day after opening... A tour of the clinic was conducted on 4/5/23 at 12:15 PM with Employee Identifier (EI) # 1, Clinic Manager. 1. In the medicine cabinet the following medications were opened and not labeled: Dodex (cyanocobalamine) one ml (milliliter) multidose vial was opened, no label was on the vial indicating the date the vial was opened. Lidocaine 1 %, two ml single dose vial was opened and in the medicine cabinet for patient use. 2. In the laboratory area the following out of date supplies were observed: Two red top vaccutainer tubes with expiration dates of 8/31/17 and 12/31/19. One purple top vaccutainer tube with an expiration date of 9/30/22. One Hemo Cue Hb-201 test strips package with expiration date of 10/20/21. Nineteen OSOM Card pregnancy test kit packages with expiration date of 2/23/23. In an interview conducted on 4/6/23 at 1:30 PM, EI # 1 confirmed the clinic failed to ensure all medications had been labeled and/or discarded after opening and all supplies had been discarded after expiration date.
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 interviews with staff, it was determined the agency failed to ensure all basic requirements for laboratory services were available to patients served. This deficient practice had the potential to negatively affect all patients served by the clinic. Findings include: Clinic policy: Laboratory Services Provided at the Clinic Policy number: none provided Reviewed: 1/10/23 ...Hemoglobin or hematocrit... A tour of the clinic laboratory area was conducted on 4/5/23 at 12:15 PM with Employee Identifier (EI) # 1, Clinic Manager. A HemoCue Hb-201 hemoglobin testing unit was observed with a package of testing strips with an expiration date of 10/20/21. EI # 1 stated the clinic did not perform hemoglobin or hematocrit testing at the clinic and was unsure if they ever had. EI # 1 further stated the clinic sends all of their lab samples to the hospital for testing. In an interview conducted on 4/6/23 at 1:30 PM, EI # 1 confirmed the clinic failed to perform all required laboratory testing.
J0161	PROGRAM EVALUATION § 491.11 Program evaluation. (a) The clinic or center carries out, or arranges for, a biennial evaluation of its total program. (b) The evaluation includes review of: (1) The utilization of clinic or center services, including at least the number of patients served and the volume of services; (2) A representative sample of both active and closed clinical records; and (3) The clinic's or center's health care policies. (c) The purpose of the evaluation is to determine whether: (1) The utilization of services was appropriate; (2) The established policies were followed; and (3) Any changes are needed. This STANDARD is not met as evidenced by: Based on review of the Strategic Financial and Operational Assessment and interview with staff, it was determined the clinic failed to ensure a biennial review of the clinic program was conducted as required. This deficient practice had the potential to affect all patients served by this clinic. Findings include: On 4/5/23 at 11:45 AM a copy of the biennial Program Evaluation was requested. On 4/6/23 at 8:30 AM a copy of the Strategic Financial and Operational Assessment conducted by an independent financial consultant group dated 12/9/22 was provided. This report included an assessment of the clinic hours, clinic volumes, revenue, and the number of encounters for each provider. The report was submitted and reviewed by the Administrator, Clinic Medical Director, Clinic Nurse Practitioner, and the Clinic Manager on 12/9/22. The clinic failed to ensure the Program Evaluation included an evaluation of the providers by a medical doctor or doctor of osteopathy and a review of active and closed clinical records. No other documentation of a Program Evaluation for prior years was provided. In an interview conducted on 4/6/23 at 8:55 AM, Employee Identifier # 3, Administrator, confirmed the clinic failed to ensure a complete Program Evaluation was conducted at least every two years.