Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 01C0001010 (X3) Date Survey Completed 09/19/2019
Name of Provider or Supplier The Southern Alabama Surgery Center, Llc Street Address, City, State 2800 Ross Clark Circle, Suite 3, Dothan, 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)
Q0221 NOTICE OF RIGHTS
CFR(s): 416.50(a)

An ASC must, prior to the start of the surgical procedure, provide the patient, or the patient's representative, or the patient's surrogate with verbal and written notice of the patient's rights in a language and manner that ensures the patient, the representative, or the surrogate understand all of the patient's rights as set forth in this section. The ASC's notice of rights must include the address and telephone number of the State agency to which patients may report complaints, as well as the Web site for the Office of the Medicare Beneficiary Ombudsman.


This STANDARD is not met as evidenced by:
Based on review of medical records (MR) and interviews with the staff it was determined the facility failed to have a new Patient Acknowledgement Form signed for each new surgery performed at the Center on each patient. This affected 3 of 20 MR's reviewed and did affect Patient Identifier (PI) # 2, PI # 3 and PI # 7 and had the potential to negatively affect all patients served by the facility.



Findings include:



1. PI # 2 was admitted to the surgery center on 1/7/19 for a EGD (esophagogastroduodenoscopy) with a Colonoscopy.



Review of the Patient Acknowledgement Form revealed a date of November 27, 2017. Further review revealed no documentation an Acknowledgement Form was signed for his/her surgery dated 1/7/19.



An interview was conducted on 9/19/19 at 4:20 PM with Employee Identifier (EI) # 2, Administrator, who confirmed the above mentioned findings.



2. PI # 3 was admitted to the surgery center on 6/11/19 for a Colonoscopy.



Review of the Patient Acknowledgement Form revealed a date of 11/2/15. Further review revealed no documentation an Acknowledgement Form was signed for his/her surgery dated 6/11/19.



An interview was conducted on 9/19/19 at 4:20 PM with EI # 2 who confirmed the above mentioned findings.



3. PI # 7 was admitted to the surgery center on 6/20/19 for a Cataract Removal.



Review of the Patient Acknowledgement Form revealed a date of 1/3/17. Further review revealed no documentation an Acknowledgement Form was signed for his/her surgery dated 6/20/19.



An interview was conducted on 9/19/19 at 4:20 PM with EI # 2 who confirmed the above mentioned findings.