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)
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 observations, clinic policy/procedure, and interviews, it was determined the clinic failed to ensure sharps containers were accessible in all technical work areas. This had the potential to affect all patients and staff at this clinic. Findings include: Clinic Policy/Procedure: Section S Blood Borne Pathogen Policy and Exposure Control Plan Policy Number: not documented Policy Date: 1/19 Purpose: To establish responsibilities and procedures for protecting patients and personnel from blood borne pathogens...through contact with blood and body fluids. ...A. Methods of Compliance ...3. Contaminated sharps shall be placed in appropriate puncture resistant, leak-proof containers...Contaminated sharps containers shall be easily accessible to employees... Engineering Controls ...Sharps containers are to be kept in an upright position in readily accessible locations in the clinic. ...Containers are constructed in a manner to prevent spillage or protrusion of contents. They are color coded and closable... Clinic Policy/Procedure: Clinic Laboratory Procedures Policy Number: not documented Policy Date: 1/19 The following policies and procedures apply when a patient has lab work performed and/or blood drawn for a lab procedure: ...14. Disposal of Specimens and Contaminated Materials: ...a. Tubes...with blood or serum should be placed in the sharps safety disposable containers in the technical work area. ...b. Dispose of needles, syringes, and blades only in sharps safety disposable containers designated for used hypodermic equipment... 1. An observation of the staff performing a venipuncture for the purpose of obtaining a laboratory blood sample was conducted on 1/3/24 at 8:25 AM. Employee Identifier (EI) # 8, Laboratory Technician, escorted an unsampled patient to the lab sampling room which contained a chair and a small table. There was no sharps container visible in the room. EI # 8 placed the portable venipuncture tray on the table, donned gloves, prepped the site of the unsampled patient and performed the venipuncture with a vacutainer needle. After obtaining the blood sample via venipuncture, EI # 8, placed the contaminated needle and vacutainer tubing in the portable venipuncture tray. EI # 8 then walked down the hall approximately 20 feet to the laboratory and discarded the used needle and tubing in the sharps container. In an interview conducted on 1/3/24 at 8:50 AM, EI # 1, Manager, Clinical Services, confirmed the clinic failed to have a sharps container accessible in the technical work area.