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Based on observation, record review and interview, the facility's governing body failed to ensure expired supplies are not stored, and in use in the facility for care and services of patients beyond the manufacturer's expiration date.

Policy Reviewed:

Review of the facility's current policy on 09/17/2025 titled, "Outdated (Expired) and Unusable Drugs and Devices", Policy ID #18406073, Revision date, December 2024.
Policy: To ensure that outdated (expired), mislabeled, or otherwise unusable drugs and devices shall not be available for patient use.

Purpose: To ensure of a system in place that identifies outdated and unusable drugs and devices and prevents their distribution and administration in the clinic.

Procedure: Definition of Unusable Drugs and Devices. Unusable supplies include those that are: Expired, Recalled, Contaminated, Broken or Deteriorated, Mislabeled, Otherwise Unsuitable for Administration or Use.

Identification of Expired Supplies: Clinical Manager shall identify outdated and other unusable drugs and devices and prevent their distribution and administration. A qualified designee (Site Supervisor) shall survey for outdated and otherwise unusable drugs and devices during the monthly inspection of the facility.

Clinical personnel who discover outdated and other unusable drugs and devices, and containers with worn illegible, or missing labels, shall return them to pharmacy for proper disposition.

Staff who discover expired supplies or with worn, illegible, or missing labels, shall return them to the Materials Manager for proper disposition.

Expiration Date Interpretation:

If an expiration date is expressed only as a month and year, the date of expiration shall be the conclusion of the last day of the stated month.

If an expiration date is expressed as a month, day and year, the date of expiration shall be at the conclusion of the stated day.


Findings:

Observation of the emergency room treatment area on 09/16/2025 at 10:30 a.m. The following expires supplies were co-mingled with stocks in use:

Emergency Room #2

8 - BD Plastipack 3 ml syringes, Expiration date 08/31/2025.

Interview on 09/16/2025 at 10:30 a.m. with Registered Nurse (Q) confirmed the above findings.

Based on record review and interview, the facility failed to include and /or evaluate contract services through the facility Quality Assessment Performance Improvement Program.

Findings included:

Review of facility "Quality Assurance & Performance Improvement (QAPI) Program", dated July 2025, showed: "Purpose to identify organization wide concerns affecting patient care, environmental safety, and general operations of the facility through the use of available data sources, focused on quality, safety, and prevention.

This policy apples to all organized services and those services provided under contract, all departments and units of the organization and all health care professionals.

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Review of a sample of signed agreements for current contracted services showed the following:

-Dietary Consulting Agreement- facility contracts with a registered dietician [ Staff ID # T ] to provide various services related to patent nutritional needs and regulatory requirements (contract signed 10/03/2023).

-Laboratory Service Agreement - [Laboratory Corporation of America] - facility contracts with them to provide laboratory testing services; specimen pick up; and report delivery [contract signed 9/24/2001].

-Vestis Uniforms and Workplace Supplies : facility contracts with them to provide linens & gowns for the patents , towels, and some cleaning equipment. [contract signed 11/19/2024)

Review of QAPI and Medical Executive Committee (MEC) meeting minutes for 2024 and 2025 year-to-date , failed to show any data/ metrics reported and evaluated for the above 3 listed contracted services.

On 9/18/2025 at 1 PM , these findings were discussed and verified with Staff ID # G, Quality Director.