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FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING: ______________________
11/21/2014
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Survey Introduction
On November 21, 2014, Department surveyors
visited the licensed abortion or reproductive
health center operated by Planned Parenthood of
Alabama (" the Center "), located at 717 West
Downtowner Loop, Mobile, Alabama to conduct
an on-site annual survey. During the visit the
following deficiencies were cited and require a
plan of correction.
L 100 ALABAMA LICENSURE DEFICIENCIES
L 100
STATE FORM
TITLE
6899
072611
(X6) DATE
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PRINTED: 08/13/2015
FORM APPROVED
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IDENTIFICATION NUMBER:
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11/21/2014
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26-14-1. Definitions.
For the purposes of this chapter, the following
terms shall have the meanings respectively
ascribed to them by this section:
(1) Abuse. Harm or threatened harm to a child's
health or welfare. Harm or threatened harm to a
child's health or welfare can occur through
nonaccidental physical or mental injury, sexual
abuse or attempted sexual abuse or sexual
exploitation or attempted sexual exploitation.
"Sexual abuse" includes the employment, use,
persuasion, inducement, enticement, or coercion
of any child to engage in, or having a child assist
any other person to engage in any sexually
explicit conduct or any simulation of the conduct
for the purpose of producing any visual depiction
of the conduct; or the rape, molestation,
prostitution, or other form of sexual exploitation of
children, or incest with children as those acts are
defined by Alabama law. "Sexual exploitation"
includes allowing, permitting, or encouraging a
child to engage in prostitution and allowing,
permitting, encouraging or engaging in the
obscene or pornographic photographing, filming,
or depicting of a child for commercial purposes.
(2) Neglect. Negligent treatment or
maltreatment of a child, including the failure to
provide adequate food, medical treatment,
supervision, clothing, or shelter.
Health Care Facilities
STATE FORM
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A. BUILDING: ______________________
11/21/2014
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6899
072611
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FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING: ______________________
11/21/2014
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L 100
Policy:
PPSE (Planned Parenthood Southeast) protects
the safety of our minor clients and complies with
state-mandated reporting laws in Georgia,
Alabama, and Mississippi. Our work in
reproductive and sexual health means all staff
must understand how to identify and respond to
sexual abuse, neglect and victimization of teens.
Teens, particularly young teens, who are in a
sexual relationships may be in unsafe
relationships and are at risk of being abused. Our
priority is to protect the safety of our clients and
comply with the law.
State: Alabama
What to report:
Rape
Definition of minor
Report sexual intercourse:
Minor is between 12 and 16 with any person 2 or
more years older than the minor.
How to report:
If abuse or neglect is identified or suspected,
initiate the following reporting process:
1. Clinic Manager or designee will contact by
telephone the local police, if indicated, and other
duly constituted authority to make a report. ( see
where to report below.)
2. The Clinician shall make a note of the
telephone notification in the minor's medical
record.
3. Clinic Manager will submit a written report, if
indicated, to the DHR(Department of Human
Services)/DFACS (Division of Family and
Children Services) (required for Alabama clinics).
A copy of the report will be placed in the minors
Health Care Facilities
STATE FORM
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medical record.
4. Clinic Manager will notify the respective
Director of Clinical Services a report was made
and will keep a record of all incidents reported.
1. MR # 16 was seen in the facility on 4/9/14 for
counseling. Review of the History and Physical
dated 4/9/14 revealed MR # 16 was 14 years old
and had 2 living children given in separate births.
There was no documentation in the medical
record of the facility reporting suspected abuse to
the proper authorities as required by Ala. Code
Reporting of Child Abuse or neglect.
An interview was conducted on 11/21/14 at 1:50
PM with Employee Identifier (EI) # 5, Director of
Patient Services who verified a report was not
made.
6899
072611
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FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING: ______________________
11/21/2014
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C4911
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6899
072611
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FORM APPROVED
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A. BUILDING: ______________________
11/21/2014
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B. WING _____________________________
C4911
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ID
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L 100
6899
072611
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FORM APPROVED
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11/21/2014
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B. WING _____________________________
C4911
NAME OF PROVIDER OR SUPPLIER
ID
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L 100
6899
072611
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FORM APPROVED
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IDENTIFICATION NUMBER:
A. BUILDING: ______________________
11/21/2014
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B. WING _____________________________
C4911
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ID
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L 100
6899
072611
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FORM APPROVED
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11/21/2014
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B. WING _____________________________
C4911
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6899
072611
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FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING: ______________________
11/21/2014
(X4) ID
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B. WING _____________________________
C4911
NAME OF PROVIDER OR SUPPLIER
ID
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L 100
6899
072611
If continuation sheet 11 of 15
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FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING: ______________________
11/21/2014
(X4) ID
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B. WING _____________________________
C4911
NAME OF PROVIDER OR SUPPLIER
ID
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COMPLETE
DATE
L 100
6899
072611
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FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING: ______________________
11/21/2014
(X4) ID
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B. WING _____________________________
C4911
NAME OF PROVIDER OR SUPPLIER
ID
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L 100
6899
072611
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PRINTED: 08/13/2015
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING: ______________________
11/21/2014
(X4) ID
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B. WING _____________________________
C4911
NAME OF PROVIDER OR SUPPLIER
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COMPLETE
DATE
L 100
6899
072611
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FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING: ______________________
11/21/2014
(X4) ID
PREFIX
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B. WING _____________________________
C4911
NAME OF PROVIDER OR SUPPLIER
ID
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(X5)
COMPLETE
DATE
L 100
6899
072611
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