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 013430 (X3) Date Survey Completed 04/06/2023
Name of Provider or Supplier Hill Hospital Physicians Clinic Street Address, City, State 724 Derby Drive, York, 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, and interview with staff, it was determined the clinic failed to ensure preventive maintenance (PM) was conducted on all electrical equipment in the clinic to ensure safety. This deficient practice had the potential to affect all patients treated at this clinic. Findings include: Clinic policy: Hill Hospital Physicians Clinic Organizational Structure Policy number: none provided Reviewed: 1/10/23 ... 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... A tour of the clinic was conducted on 4/5/23 at 12:15 PM with Employee Identifier # 1, Clinic Manager. In Exam Room # 1 an electric space heater was located, no PM sticker was on the unit and no documentation of inspection was provided. In an interview conducted on 4/6/23 at 1:30 PM, EI # 1 confirmed the clinic failed to ensure the electric space heater had been inspected for safety by the maintenance department. EI # 1 further stated the heater had been removed from the clinic since the tour on 4/5/23.