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 01C0001013 (X3) Date Survey Completed 06/12/2025
Name of Provider or Supplier Op Surg Ctr, Inc And Surgicare Of Huntsville, Inc Street Address, City, State 721 Madison Street, Huntsville, 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)
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 observations, review of facility policy and procedure, and staff interviews, it was determined the facility failed to ensure staff performed hand hygiene per facility policy.

This did affect Patient Identifier (PI) # 19, one unsampled patient, PI # 20, and had the potential to affect all patients served by the facility.

Findings include:

Facility Policy: Hand Hygiene

Policy Number: 116.0

Date: Not Listed

Purpose:

To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs, and infections.

Policy:

All members of the healthcare team will comply with current Centers for Disease Control and Prevention (CDC) and AORN (Association of periOperative Registered Nurses) hand hygiene guidelines on when to use non-bacterial soap and water, an antimicrobial soap and water or an alcohol-based hand rub.

Procedure:

I. Indications For Handwashing 

...C. Hand-washing may also be used for routinely decontaminating hands in the following clinical situations:

 1. Before having direct contact with patients.

 2. Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. 

 3. After contact with a patient's intact skin (e. g. [for example], when taking a pulse or blood pressure, and lifting a patient).

 4. After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings...

 5. When moving from a contaminated body site to a clean body site during patient care.

 6. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

 7. After removing gloves.

II. Indications for Hand-rubbing

A. If hands are not visibly soiled, an alcohol-based hand sanitizer containing 60-95 % (percent) may be used for routinely decontaminating hands in the following clinical situations:

1. Before having direct contact with patients.

 2. Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. 

 3. After contact with a patient's intact skin (e. g. [for example] , when taking a pulse or blood pressure, and lifting a patient).

 4. After contact with body fluids or excretions, mucous membranes , non-intact skin and wound dressings...

 5. When moving from a contaminated body site to a clean body site during patient care.

 6. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

 7. After removing gloves.

III. Non-Surgical Hand Hygiene Technique

...D. Gloves and Hand Hygiene: ...

 1. Wear gloves when contact with blood or other potentially infectious  materials (other body fluids, secretions and excretions), mucous membranes, non-intact skin and contaminated items will or could occur.

 2.  Change gloves during patient care if moving from a contaminated body site to a clean body site.

 3. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient

 4. Decontaminate hands after removing gloves.


2. An observation was conducted on 6/10/25 at 10:13 AM. EI # 16, PACU Technician, obtained Vesa Sure disinfectant wipes, cleaned a dirty bed mattress, handrails, pillow and blood pressure cuff.  EI # 16 obtained a clean sheet with contaminated gloves and placed on the cleaned bed. EI # 16 failed to remove the contaminated gloves and perform hand hygiene before he/she obtained a clean sheet.

EI # 16 then gathered two dirty linen bags and carried them to the soiled utility room. EI # 16 returned to the PACU bed cleaning section, removed contaminated gloves and without performing hand hygiene donned clean gloves. EI # 16 then obtained Vesa Sure disinfectant wipes, wiped the next bed mattress, handrails, pillow and blood pressure cuff. EI # 16 failed to perform hand hygiene after the removal of contaminated gloves.

An interview was conducted on 6/10/25 at 10:20 AM with EI # 22, RN, who confirmed EI # 16 failed to remove contaminated gloves and perform hand hygiene per facility policy.

3. An observation was conducted on 6/11/25 at 8:05 AM. EI # 15, RN took PI # 20's vital signs, cleaned vital sign equipment with Clorox wipes. EI # 15 then removed contaminated gloves, without performing hand hygiene applied clean gloves and assessed PI # 20's right arm for IV catheter insertion.

An interview was conducted on 6/12/25 at 2:40 PM, EI # 1, who confirmed the staff failed to perform hand hygiene per facility policy. 

An observation of care was conducted on 6/10/25 at 10:43 AM. Employee Identifier (EI) # 6, Pre-Op (Pre-Operative) RN ( Registered Nurse), without performing hand hygiene, weighed and admitted PI # 19 to the Pre-Op area, Bay # 20. 

EI # 7 (Pre-Op RN), without performing hand hygiene, donned gloves to obtain PI # 19's vital signs. The initial blood pressure cuff did not inflate correctly. The cuff was removed and cleaned with a Cavi-Wipe. While wearing the same pair of gloves used to clean the blood pressure cuff, a second cuff was applied to obtain PI # 19's blood pressure. The second cuff and cords were cleaned, the contaminated gloves were removed and hand hygiene was not performed.

Without performing hand hygiene, EI # 7 gathered and opened supplies to start PI # 19's  IV (Intravenous) catheter, including spiking the IV bag. 

EI # 6 and EI # 7, did not perform hand hygiene according to facility policy.

An observation was conducted on 6/10/25 at 11:31 AM of an unsampled patient receiving a blood glucose check. EI # 9, Pre-Op RN, after obtaining the blood sugar, and wearing the same contaminated gloves, obtained a Cavi-Wipe, cleaned the glucometer and returned it to a counter in the Pre-Op area. EI # 9 removed the contaminated gloves and without performing hand hygiene, re-entered the unsampled patient's bay.

EI # 9 did not perform hand hygiene according to facility policy.

The observation of PI # 19 continued at 12:03 PM, when EI # 8, Anesthesiologist entered PI # 19's Bay, and without performing hand hygiene, performed a brief physical assessment. EI # 8 exited the patient's bay and did not perform hand hygiene.

At 2:07 PM, EI # 10, CRNA (Certified Registered Nurse Anesthetist) and EI # 11, Circulating RN, entered PI # 19's patient bay and without performing hand hygiene, donned gloves to transport PI # 19 to the OR ( operating room).

After surgery was completed, PI # 19 was transported to the PACU (Post Anesthesia Care Unit). EI # 13, PACU RN, without performing hand hygiene, donned gloves and cared for the patient.

EI # 8, # 10, # 11, and # 13 did not perform hand hygiene according to the facility policy.

An interview was conducted on 6/12/25 at 2:40 PM with EI # 1, Director of Nursing, who confirmed the staff did not perform hand hygiene according to facility policy.