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)
J0070 RECORDS SYSTEM
CFR(s): 491.10(a)(3)

For each patient receiving health care services, the clinic ... maintains a record that includes, as applicable: (i) Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; (ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings; (iii) All physician's orders, reports of treatments and medications and other pertinent information necessary to monitor the patient's progress; (iv) Signatures of the physician or other health care professional.


This STANDARD is not met as evidenced by:
Based on review of medical records (MR's) and interviews with the staff it was determined the facility failed to ensure each patient's MR contained a signed consent for treatment form. This affected 4 of 10 MR's reviewed and did affect MR # 1, MR # 4, MR # 6 and MR # 7 and had the potential to negatively affect all patients served by the facility. Findings include: Review of 10 MR's revealed the facility failed to ensure all patients signed a consent for treatment form prior to being seen by the physician or the nurse practitioner. Review of MR # 1, MR # 4, MR # 6 and MR #7 revealed no signed consent forms within the patient's medical record. An interview was conducted on 2/7/18 with Employee Identifier (EI) # 1, Office Manage, who confirmed the above mentioned findings.