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 013422 (X3) Date Survey Completed 01/03/2024
Name of Provider or Supplier Ochsner Health Center-Butler Street Address, City, State 1404 E Pushmataha Street, Butler, 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)
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/procedure, and interviews, it was determined the clinic failed to ensure opened multidose vials were not available for patient use beyond the expiration dates. This had the potential to affect all patients treated at this clinic. Findings included: Clinic Policy/Procedure: Medication Storage and Handling Policy Number: not documented Revised Date: 4/28/23 Medications and biologicals shall be stored to ensure their integrity, stability, and effectiveness... Handling of multi-dose medications in the RHC (Rural Health Clinic) will be as follows: ...3. Upon opening, the healthcare personnel will immediately write the following on the label: a. Date opened... Unless otherwise specified, all multi-dose medications should be discarded 28 days after opening, or at expiration date (whichever occurs first). Vaccines are discarded on expiration date... 1. An observation of the medication storage area was conducted on 1/2/24 at 11:00 AM with Employee Identifier (EI) # 4, Licensed Practical Nurse (LPN). In the medication storage cabinet, the surveyor observed one Dexamethasone 30 milliliter multidose vial with a label indicating the vial was opened on 11/13/23. Per clinic policy, the opened multidose vial should have been discarded after 28 days on 12/11/23. In an interview conducted on 1/3/24 at 2:00 PM, EI # 1, Manager, Clinic Operations, confirmed the clinic failed to ensure expired medications were not available for patient use.