Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 013420 (X3) Date Survey Completed 06/08/2023
Name of Provider or Supplier Lake Martin Family Medicine Street Address, City, State 301 Mariarden Rd Suite D, Dadeville, 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)
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 review of policies and procedures, observation and interviews, it was determined the clinic failed to ensure medical supplies available for patient use were not expired. This deficient practice had the potential to negatively affect all patients served by the clinic. Findings include: Clinic Policy: Drugs and Biological Storage Plan Policy Number: Not documented Date: Not documented In order to assure that drugs and biologicals are properly cared for, the following steps are taken: ...4. ...stock is rotated when a fresh supply comes in. Old reserves are moved to the front and used before new supplies. Upon receipt of new stock, expiration dates are checked on old stock and those expired drugs and biologicals are disposed of... ...10. A search for expired drugs, solutions and injections will take place once a month in the sample room, emergency kit, refrigerator and other drug storage areas. Clinic Policy: Access and Security of Drugs Policy Number: Not documented Date: Not documented Extreme care must be exercised that no expired medications are dispensed for patient use or allowed to remain in the clinic. 1. The clinic personnel will check monthly all medications physically for dated items and remove all expired packages from the shelves. ...5. The expiration dates on all medications will be monitored monthly and documented. 1. A tour of the clinic was conducted on 6/6/23 at 11:00 AM with Employee Identifier (EI) # 1, Office Manager. The following medical supplies were observed to be expired and available for patient use. Fourteen bottles of 10 percent (%) Neutral Buffered Formulin containing 20 milliliter (ml) per bottle with an expiration date of 5/23. One Becton Dickenson speckle top vacutainer blood collection tube with an expiration date of 12/31/21. Eight Thin Prep Pap Test bottles with an expiration date of 6/2/23. One Iodoform Gauze 1/2 inch by 5 yards with an expiration date of 5/23. One sealed 1000 ml bottle of Normal Saline with an expiration date of 4/5/22. Two 1% Lidocaine Hydrochloride (HCl) 50 ml multiple dose vials (mdv) opened but no date when opened or for expiration of beyond use date (bud). One Promethazine 25 milligram (mg) ampule with an expiration date of 4/23. An interview was conducted on 6/6/23 at 11:53 AM with EI # 1, who confirmed the above supplies were expired and available for patient use.