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)
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, and interview, it was determined the clinic failed to ensure expired medication, laboratory (lab) controls, and patient care supplies were not available for patient use to ensure patient safety. Findings include: Clinic Policy: STORAGE, HANDLING & ADMINISTRATION OF DRUGS, BIOLOGICALS, AND PHARMACEUTICALS Policy number: 220.0 Date: 3/10/2025 Policy Purpose: The purpose of this policy is to outline the procedures related to the storage and handling of drugs, biological and pharmaceuticals. Policy Body: Storage, Handling and Administration of Drugs, Biologicals, and Pharmaceuticals 1. General Storage and Handling Guidelines... o. All drugs and biologicals shall be inventoried for expiration dates (beyond use dates) on a monthly basis by a designated staff member, usually a member of the nursing staff or medical assistant. The Clinic Manager shall periodically spot check the supply area to ensure compliance. 1. A tour of the medication storage/ preparation room was conducted on 12/9/2025 at 11:00 AM with Employee Identifier (EI) # 2, Office Manager. The following expired medications were observed in the medication room: a. Six packs of Slynd 28 tablets blister pack with an expiration (exp) date of 11/2025. b. One Vitafol Ultra Unit dose pack (3 softgel caps) with an exp date of 6/2025. c. Forty packs of Imvexxy 10 micrograms (mcg) vaginal inserts with an exp date of 10/2025. d. Seven Clonidine 0.1 milligram (mg) tablet blister packs with an exp date of 10/2025. e. One opened multi-dose vial of Delestrogen 100 mg/5 milliliter (ml) with exp date of 1/2026 and no opened date/use by date indicated. f. One opened multi-dose vial of Testosterone Cypionate 200 (mg/ml) with exp date of 5/2027 and no opened date/use by date indicated. 2. A tour of the medication storage room # 2 was conducted on 12/9/2025 @ 11:30 AM with EI # 2. The following expired medications were observed in the medication storage room: a. Six vials of QC Hemoglobin Control/multi level with an exp date of 8/31/2025. b. One opened vial of Admelog 100 units/ml with no use by date indicated. 3. A tour of the reception area was conducted on 12/9/2025 at 1:00 PM and the following deficiencies were observed: One container of low glucose monitoring solution with an exp date of 7/23/2025 was observed. One container of high glucose monitoring solution with an exp date of 7/23/2025 was observed. During the tour EI # 2 confirmed the clinic failed to ensure that exp pharmaceuticals were unavailable for patient use per clinic policy to ensure patient safety.