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)
Q0221 NOTICE OF RIGHTS
CFR(s): 416.50(a)

§416.50(a) Standard: Notice of Rights An ASC must, prior to the start of the surgical procedure, provide the patient, 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 the written notice of patient rights, facility policy and staff interview, it was determined the facility failed to include the State Agency Hotline phone number 1 (800) 356-9596 to which patients may report complaints or grievances.


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


A review of the written notice of Patients Rights documents revealed the State Agency Hotline phone number 1 (800) 356-9596, for patients to report complaints was not included in the information provided to the patient.


An interview was conducted on 12/6/23 at approximately 12:04 PM with Employee Identifier (EI) # 1, Practice Administrator, who confirmed the staff failed to provide the State Agency Hotline number to the patients.