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 12/10/2025
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)
J0042 PHYSICAL PLANT AND ENVIRONMENT

491.6(b) Maintenance: The clinic . . . has a preventive maintenance program to ensure that: (1) All essential mechanical, electrical and patient-care equipment is maintained in safe operating condition;


This STANDARD is not met as evidenced by:
Based on observations, clinic policy, interviews with staff, and manufacturer's directions for use (MDFU) it was determined the clinic failed to ensure preventive maintenance (PM) was conducted on all electrical equipment in the clinic to ensure patient and staff safety. This had the potential to affect all patients treated at this clinic. Findings include: Clinic Policy: PREVENTIVE AND REQUIRED MAINTENANCE Policy number: 210.0 Date: 10/22/2020 Policy Purpose: The purpose of this policy is to outline the procedures related to preventive and/or required maintenance. Policy Body: Preventive Maintenance... 2. Biomedical and Equipment Used to Deliver Patient Care a. The clinic shall maintain a service agreement or have an arrangement to routinely inspect and maintain equipment related to direct patient care, diagnostic procedures, or therapeutic procedures. The agreement or arrangement shall provide for: i. An initial inspection of all bio-medical equipment shall be made in preparation for initial RHC certification. ii. Regularly scheduled inspections shall be conducted at subsequent intervals which shall not exceed 12 months from the initial inspections (at least annually). Contour Next blood glucose Control Solution Testing, and Quality Control MDFU ... You should perform a control test when: Using the meter for the first time, you open a new bottle or package of test strips, you think your meter may not be working correctly, or if you have repeated, unexpected blood glucose results. 1. A tour of the clinic was conducted on 12/9/2025 at 09:30 AM with Employee Identifier (EI) # 2. The following deficiencies were observed: A Welch Allyn (brand) Otoscope with a PM label dated 02/2020 and electric exam table with no PM label were observed in Exam room # 1. A Welch Allyn Otoscope with a PM label dated 02/2020, an electric exam table and floor base exam light with no PM labels were observed in Exam room # 2. A Welch Allyn Otoscope and electric exam table with no PM labels were observed in Exam room # 3. A weighing scale with an unreadable PM label and a Welch Allyn Otoscope with a PM label dated 07/2021 were observed in the triage area. A portable suction machine with no PM label was observed on top of the crash cart in the hallway. A small refrigerator used for medication storage with a PM label dated 3/2019 was observed in the Medication room. No equipment maintenance log or documentation of equipment management was provided. During the tour EI # 2, Office Manager, confirmed the clinic failed to ensure PM was performed annually per policy on all patient care electrical equipment to ensure patient and staff safety. 2. A tour of the reception area was conducted on 12/9/2025 at 1:00 PM and the following deficiencies were observed: A Contour Next (brand) blood glucose meter was observed in the reception area for use in patient care. There was no documentation of quality control testing for the blood glucose meter. EI # 2, Office Manager confirmed there was no documentation of quality control testing for the blood glucose meter to ensure patient safety per company policy.