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751 DERBY DRIVE YORK, AL 36925 | Government - Hospital District or Authority

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Health deficiencies are assigned during inspections that assess compliance with rules related to patient health and safety. Examples include violations of patients' rights and safety standards, as well as the administration of drugs and other treatments.

Life Safety deficiencies are assigned during inspections that assess a facility's compliance with National Fire Protection Association codes related to life safety in health care facilities. They are often conducted in tandem with health inspections. Examples include faulty or improperly maintained fire suppression and electrical systems.

Emergency Preparedness deficiencies can be cited during either a health or life safety inspection and relate to violations of CMS' Emergency Preparedness Rule. Examples include a lack of emergency plans, inadequate staff training and insufficient emergency supplies.

Complete reports and deficiency counts

Report date	Health Deficiencies	Life Safety	Emergency Preparedness	Total
Feb 8, 2024	1	0	0	1	Read full report
Deficiencies cited in this report: MAINTENANCE OF PHYSICAL PLANT
Feb 16, 2023	3	0	0	3	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM APPROPRIATE TRANSFER
Mar 10, 2022 Follow-up to inspection on 2022-01-19*	10	0	0	10	Read full report
Deficiencies cited in this report: GOVERNING BODY PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING STAFFING AND DELIVERY OF CARE ADMINISTRATION OF DRUGS ORGANIZATION INFECTION CONTROL PROGRAM INFECTION CONTROL SURVEILLANCE, PREVENTION DISCHARGE PLANNING EVALUATION EMERGENCY SERVICES POLICIES
Jan 19, 2022	22	0	3	25	Read full report
Deficiencies cited in this report: NURSING SERVICES STAFFING AND DELIVERY OF CARE ADMINISTRATION OF DRUGS BLOOD TRANSFUSIONS AND IV MEDICATIONS MEDICAL RECORD SERVICES CONTENT OF RECORD MEDICAL RECORD SERVICES CONTENT OF RECORD: ORDERS DATED & SIGNED CONTENT OF RECORD: CONSULTATIVE RECORDS CONTENT OF RECORD: ORDERS,NOTES,REPORTS PHARMACY ADMINISTRATION ORGANIZATION PHYSICAL ENVIRONMENT INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM INFECTION CONTROL SURVEILLANCE, PREVENTION ANTIBIOTIC STEWARDSHIP PROGRAM ANTIBIOTIC STEWARDSHIP COORDINATION ANTIBIOTIC STEWARDSHIP EVIDENCE BASED DISCHARGE PLANNING EVALUATION DISCHARGE PLANNING-D/C PLANNING LIST QUALIFIED EMERGENCY SERVICES PERSONNEL Procedures for Tracking of Staff and Patients Policies/Procedures-Volunteers and Staffing EP Testing Requirements
Jan 11, 2022	0	5	0	5	Read full report
Deficiencies cited in this report: Egress Doors Fire Alarm System - Testing and Maintenance Corridor - Doors Utilities - Gas and Electric Portable Space Heaters
Sep 23, 2020	2	0	0	2	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM
Jan 22, 2018	13	0	0	13	Read full report
Deficiencies cited in this report: GOVERNING BODY MEDICAL STAFF - ACCOUNTABILITY EMERGENCY SERVICES EMERGENCY SERVICES MEDICAL STAFF MEDICAL STAFF BYLAWS ORGANIZATION OF MEDICAL STAFF UNUSABLE DRUGS NOT USED EMERGENCY SERVICES ORGANIZATION OF EMERGENCY SERVICES EMERGENCY SERVICES POLICIES EMERGENCY SERVICES PERSONNEL QUALIFIED EMERGENCY SERVICES PERSONNEL
Jan 18, 2018	3	0	0	3	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 EMERGENCY ROOM LOG MEDICAL SCREENING EXAM
May 23, 2017 Follow-up to inspection on 2017-03-02*	2	0	0	2	Read full report
Deficiencies cited in this report: STAFFING AND DELIVERY OF CARE NURSING CARE PLAN
Apr 19, 2017 Follow-up to inspection on 2017-03-02*	13	0	0	13	Read full report
Deficiencies cited in this report: GOVERNING BODY CHIEF EXECUTIVE OFFICER MEDICAL STAFF CREDENTIALING NURSING SERVICES NURSING CARE PLAN ADMINISTRATION OF DRUGS FORM AND RETENTION OF RECORDS Standard-level Tag for Pharmaceutical Service PHARMACIST RESPONSIBILITIES UNUSABLE DRUGS NOT USED INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM
Mar 2, 2017	25	0	0	25	Read full report
Deficiencies cited in this report: GOVERNING BODY CHIEF EXECUTIVE OFFICER QAPI DATA COLLECTION & ANALYSIS QUALITY IMPROVEMENT ACTIVITIES QAPI GOVERNING BODY, STANDARD TAG MEDICAL STAFF CREDENTIALING NURSING SERVICES STAFFING AND DELIVERY OF CARE NURSING CARE PLAN ADMINISTRATION OF DRUGS FORM AND RETENTION OF RECORDS CONTENT OF RECORD Standard-level Tag for Pharmaceutical Service PHARMACY ADMINISTRATION PHARMACIST RESPONSIBILITIES PHARMACY PERSONNEL DELIVERY OF DRUGS UNUSABLE DRUGS NOT USED ORGANIZATION PHYSICAL ENVIRONMENT FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM
Mar 1, 2017	0	12	0	12	Read full report
Deficiencies cited in this report: Means of Egress - General Cooking Facilities Fire Alarm System - Testing and Maintenance Sprinkler System - Maintenance and Testing Portable Fire Extinguishers Corridor - Doors Subdivision of Building Spaces - Smoke Barrie Utilities - Gas and Electric HVAC Electrical Systems - Essential Electric Syste Gas Equipment - Cylinder and Container Storag Gas Equipment - Qualifications and Training
Mar 27, 2014 Follow-up to inspection on 2014-02-13*	2	0	0	2	Read full report
Deficiencies cited in this report: ADMINISTRATION OF DRUGS INFECTION CONTROL PROGRAM
Feb 13, 2014	28	0	0	28	Read full report
Deficiencies cited in this report: MEDICAL STAFF - BYLAWS AND RULES PATIENT RIGHTS: GRIEVANCES PATIENT RIGHTS: INFORMED DECISION QAPI DATA COLLECTION & ANALYSIS NURSING SERVICES STAFFING AND DELIVERY OF CARE ADMINISTRATION OF DRUGS ORDERS FOR DRUGS AND BIOLOGICALS MEDICATION SELF-ADMINISTRATION Standard-level Tag for Pharmaceutical Service PHARMACY ADMINISTRATION PHARMACIST RESPONSIBILITIES PHARMACIST SUPERVISION OF SERVICES UNUSABLE DRUGS NOT USED MONITORING RADIATION EXPOSURE QUALIFIED DIETITIAN PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM SWING BEDS No Description Available No Description Available No Description Available No Description Available No Description Available
Feb 11, 2014	0	17	0	17	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available
Mar 30, 2011 Follow-up to inspection on 2011-02-22*	0	4	0	4	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available
Feb 22, 2011	0	13	0	13	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available
Feb 17, 2011	6	0	0	6	Read full report
Deficiencies cited in this report: LICENSURE OF PERSONNEL PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: GRIEVANCES PHARMACIST SUPERVISION OF SERVICES UNUSABLE DRUGS NOT USED PHYSICAL ENVIRONMENT

Some state health departments and regional offices of the Centers for Medicare and Medicaid Services sometimes did not upload their inspection reports into a central computer system that could then be shared by us. In such cases, CMS identified the dates of the missing inspections and the number of deficiencies identified. You can request the actual reports from CMS or your state health department.

* Deficiencies cited in follow-up inspections are not counted toward a facility's total deficiency count.

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Complete reports and deficiency counts