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 01C0001011 (X3) Date Survey Completed 12/07/2023
Name of Provider or Supplier Gadsden Surgery Center, Ltd Street Address, City, State 418 South 5th Street, Gadsden, 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)
Q0220 NOTICE - POSTING
CFR(s): 416.50

... The ASC must also post the written notice of patient rights in a place or places within the ASC likely to be noticed by patients waiting for treatment or by the patient's representative or surrogate, if applicable.


This STANDARD is not met as evidenced by:
Based on the posted Patient Rights and Responsibilities framed document, facility policy and staff interview, it was determined the facility failed to include the State Agency Hotline phone number 1 (800) 356-9596 as part of the contact information for grievances and complaints..


This deficient practice had the potential to negatively affect all patients served by this facility.


Findings include:


Facility Policy: Patient's Rights and Responsibilities


Revision Date: 7/2023


Centers for Medicare and Medicaid Services (CMS)


The patient and the patient's representative or surrogate has the right to:


...Voice grievances regarding treatment or care that is (or fails to be) provided.


Complaint/grievance process:


...If you are not satisfied with the response of Gadsden Surgery Center you may contact the State of Alabama via:


Mail: P.O. Box 5624, Montgomery AL 36103-5624. Phone (334) 242-5000. Email or Web Address: www.mediciad.alabama.gov


During the tour of the facility on 12/5/23 at approximately 9:45 AM an observation of the posted Patient Rights and Responsibilities framed document located at the patient check in station revealed the State Agency Hotline number 1 (800) 356-9596 was not included as part of the contact information for grievances and complaints.


An interview was conducted on 12/6/23 at approximately 12:04 PM with Employee Identifier (EI) # 1, Practice Administrator, who confirmed the State Agency Hotline number was not included in the posted Patient Rights and Responsibilities framed document.