Feminist Women’s Health Center (formerly Cliff Valley Clinic)

Clinic is Limited to fetal heartbeat detection/6 weeks

2012-2014:

• Speculums not sterilized and expired
• RN and ultrasound tech had no CPR training
• Repeated violations year after year of expired medications on the crash cart, anesthesia cart, and narcotics cart for patient use
• Multidose vial of narcotic Fentanyl in use with no opened date
• The facility failed to file a certificate of abortion with the state on every patient who received the procedure at their clinic.

2017:

• This facility, by law, should have an organized governing body that sets the policies and assumes legal responsibility for the center’s conduct and compliance. The governing body failed (according to the report) to be responsible for the overall conduct of the center. This included records, personnel, physical plant, and operational standards, waste and sanitation disposal, and procedure for filing certificates of abortion to the state health department (repeat offense).
• There was no professional staff appointed to the governing body and that quality reviews were conducted.
• This facility had no appointed Nursing Supervisor. The length of time the facility has gone without a nursing supervisor was redacted on the report.
• The facility failed to ensure that medications were secure with only licensed personnel having access. There were medications being stored in an unlocked refrigerator because, according to the administrator, the “lock had been broken for a little over a month”.
• The facility did not ensure that employees had a health examination and they had no policy for follow up exams. This put the health and welfare of all staff and patients at risk.
• Personnel files had no job descriptions or evidence of orientation.
• The facility failed to conduct quarterly fire and disaster drills.
• There were no physical examinations or discharge orders for patients in 30% of the charts reviewed. This is a violation of the facility’s own policy.
• The facility failed to store biohazardous waste properly.

2018:

• The facility failed to establish an ongoing Quality Assessment and Improvement Plan or infection control program. There were no meeting minutes for the year 2018. The quality assurance plan was not discussed in any of the 2017 meeting minutes (of note, this deficiency was not cited in the 2017 inspection report).
• The facility failed to maintain hospital affiliation agreements and admitting privileges for the physicians in the event of complications. Two doctors had no admitting privileges on file.
• The facility had no infection control plan to report communicable diseases or facility infection rates and trends.
• The treatment rooms were not maintained to standard to assure the health and safety of patients. The operating room’s temperature and humidity had not been checked since the last inspection in March 2017.
• The facility did not ensure that employees had a health examination and they had no policy for follow up exams. This put the health and welfare of all staff and patients at risk. (repeat violation)
• The facility failed to conduct quarterly fire and disaster drills. (repeat violation)
• Staff failed to keep the operating room clean and the equipment in good repair. There was a 2-inch tear on the operating table preventing disinfection. The operating room (per facility policy) was to receive a terminal clean at the end of every day. The ventilator had dust and there was a waxy buildup around the knobs.
• Repeated violations year after year of expired medications on the crash cart, anesthesia cart, and narcotics cart for patient use
• There were 4 pre-filled syringes with no label on the anesthesia cart. No name of the medication, when it was drawn up, dose, etc.
• The facility failed to file a certificate of abortion as required by the state on every patient who received the procedure at their clinic within 10 days following their procedures.
• The administrator’s response to the deficiencies was that she is “new to the position and the facility was not in compliance in numerous areas”.

2021

• Lab director failed to ensure proficiency testing reports were reviewed as required
• Lab director failed to ensure lab testing personnel receive appropriate training for moderate complexity as required
• Lab director failed to employ a technical consultant qualified by education and experience