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 013429 (X3) Date Survey Completed 02/07/2018
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)
J0021 MAINTENANCE
CFR(s): 491.6(b)

The clinic ... has a preventive maintenance program to ensure that:


This STANDARD is not met as evidenced by:
Based on observations and interviews with the staff it was determined the facility failed to ensure the equipment within the facility had preventive maintance conducted at least annually by qualified personnel and all equipment was tagged with the date of the inspection and a record kept of each inspection. This had the potential to negatively affect all patients served by the facility. Findings include: A tour of the facility was conducted on 2/7/18 at 8:45 AM with Employee Identifier (EI) # 2, Nurse Practitioner. During the tour, the laboratory (lab) area was reviewed and on the counter in the lab area was a machine and when the surveyor asked EI # 2 what the machine was EI # 2 responded by saying it is the Hematocrit machine. The surveyor observed the preventive maintance sticker with a date due of 6/14 and no other sticker was present on the machine. EI # 2 confirmed the date on the sticker. Observation of exam room # 1 revealed no preventive maintance sticker on the exam room table. Review of exam room # 3 revealed an Intravenous (IV) pole, the exam light and the exam table did not have preventive maintance stickers. Review of the Triage room revealed 1 set of baby scales and 2 adult stand up scales all lacking a preventive maintance sticker. An interview was conducted on 2/7/18 at 1:00 PM with EI # 1, Office Manager and EI # 2 who confirmed the above mentioned findings.