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)
J0161 PROGRAM EVALUATION

ยง 491.11 Program evaluation. (a) The clinic or center carries out, or arranges for, a biennial evaluation of its total program. (b) The evaluation includes review of: (1) The utilization of clinic or center services, including at least the number of patients served and the volume of services; (2) A representative sample of both active and closed clinical records; and (3) The clinic's or center's health care policies. (c) The purpose of the evaluation is to determine whether: (1) The utilization of services was appropriate; (2) The established policies were followed; and (3) Any changes are needed.


This STANDARD is not met as evidenced by:
Based on review of the Strategic Financial and Operational Assessment and interview with staff, it was determined the clinic failed to ensure a biennial review of the clinic program was conducted as required. This deficient practice had the potential to affect all patients served by this clinic. Findings include: On 4/5/23 at 11:45 AM a copy of the biennial Program Evaluation was requested. On 4/6/23 at 8:30 AM a copy of the Strategic Financial and Operational Assessment conducted by an independent financial consultant group dated 12/9/22 was provided. This report included an assessment of the clinic hours, clinic volumes, revenue, and the number of encounters for each provider. The report was submitted and reviewed by the Administrator, Clinic Medical Director, Clinic Nurse Practitioner, and the Clinic Manager on 12/9/22. The clinic failed to ensure the Program Evaluation included an evaluation of the providers by a medical doctor or doctor of osteopathy and a review of active and closed clinical records. No other documentation of a Program Evaluation for prior years was provided. In an interview conducted on 4/6/23 at 8:55 AM, Employee Identifier # 3, Administrator, confirmed the clinic failed to ensure a complete Program Evaluation was conducted at least every two years.