| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001009 | (X3) Date Survey Completed 07/31/2025 |
| Name of Provider or Supplier Surgicare Of Mobile, Ltd | Street Address, City, State 2890 Dauphin St, Mobile, 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) |
| E0000 | A recertification survey was conducted on 7/29/25 to 7/31/25 and Surgicare of Mobile was found to be in substantial compliance with the Conditions for Coverage for Emergency Preparedness. |
| Q0000 | An onsite recertification survey was conducted on 7/29/25 to 7/31/25 at Surgicare of Mobile. Standard level deficiencies were cited for the Health survey and will require a Plan of Correction. Condition level deficiencies and related standards for the Life Safety survey were cited at 416.44 Environment. |
| Q0100 | ENVIRONMENT CFR(s): 416.44 The ASC must have a safe and sanitary environment, properly constructed, equipped, and maintained to protect the health and safety of patients. This CONDITION is not met as evidenced by: Based on observations during the facility tour with Ambulatory Surgery Center staff by the Life Safety Surveyor and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility. Findings include: Refer to Life Safety Code violations K 0345 and K 0351 for findings. |
| Q0241 | SANITARY ENVIRONMENT CFR(s): 416.51(a) The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice. This STANDARD is not met as evidenced by: Based on review of facility policy and procedure, observations and interviews, it was determined the facility failed to ensure staff performed hand hygiene per facility policy. This did affect Patient Identifier (PI) # 1 and had the potential to affect all patients served by the facility. Findings include: Facility Policy: Hand Hygiene Policy Number: None Reviewed Date: 07/2025 Policy Statement: ...For routine decontamination of hands in the clinical setting, use an alcohol-based waterless antiseptic. Procedure: When to use an alcohol-based waterless antiseptic ... Before preparing or administering medication. ... After removing gloves. Before donning sterile gloves... An observation of care of PI # 1 was conducted on 7/29/25 at 11:21 AM. Employee Identifier (EI) # 3, Pre-Op (Pre-Operative) RN (Registered Nurse) removed gloves, and without performing hand hygiene, charted on the electronic medical record (EMR). After EI # 3 administered eye drops to the patient, EI # 3 removed gloves and placed the eye drops in a storage basket. EI # 3 failed to perform hand hygiene after removing gloves. EI # 4, CRNA (Certified Registered Nurse Anesthetist), withdrew IV (intravenous) pre-op medication from a vial into a syringe, then administered the IV pre-op medication to PI # 1, without performing hand hygiene, prior to preparing the IV medication and prior to the administration of the IV medication. In the OR (operating room) at 12:20 PM, EI # 5, surgical tech, removed gloves used to transfer patient to the OR, and without performing hand hygiene, donned sterile gloves to prep PI # 1's eye for surgery. The facility staff failed to perform hand hygiene according to the facility policy. An interview was conducted on 7/31/25 at 12:14 PM with EI # 1, Director of Nursing, who confirmed the staff failed to perform hand hygiene according to facility policy. |