| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001000 | (X3) Date Survey Completed 11/14/2019 |
| Name of Provider or Supplier Montgomery Surgical Center Llc | Street Address, City, State 470 Taylor Road, Montgomery, 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) |
| K0000 | . K3 Building: 0101 K6 Plan Approval: 01/16/2007 K7 Survey Under: 2012 Existing K8 ASC Generator: One Diesel, Baldor 750 kW (installed 2008) FACP: Simplex - 4100U (installed 2008) Locking Devices: Magnetic full time Smoke Detection: Complete Cases per week: 270 Type of Structure: This 2007 facility is located on the first floor of a protected noncombustible, Type II(111) three story building. The facility has a complete automatic sprinkler system. During a routine recertification survey conducted on this date, the facility was found not in compliance with 42 CFR 416.44 (b) - ASC evidenced by the following deficiencies of NFPA 101 Life Safety Code (LSC) and codes referenced by the LSC, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. . |
| K0321 | Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas must meet one of the following: *Contain 1 hour rated enclosure when non-sprinklered *Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7 This STANDARD is not met as evidenced by: . Based on observation and interview, the facility failed to maintain the hazardous rooms per the requirements of: 2012 NFPA 101, 21.3.2 and 39.3.2.1 This deficiency could affect approximately 20 occupants. Findings include: On 11/14/2019, during a tour of the facility from 8:00 am to 4:45 pm, the surveyor observed Post OP Room 14 being used as a General Storage Room withthout a self-closing device on the door. A member of maintenance staff was present when this deficiency was identified. . |
| K0353 | Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: . Based on review of documentation and interview, the facility failed to maintain the automatic sprinkler system per requirements of: 2012 NFPA 101, 9.7.5 2011 NFPA 25, 5.2.4.1 This deficiency could affect approximately 20 occupants. Findings include: On 11/14/2019, during a tour of the facility from 8:00 am to 4:45 pm, the facility failed to provide documentation of the monthly inspections on the wet sprinkler riser gauges. A member of the maintenance staff was present when this deficiency was identified. . |
| K0771 | Engineer Smoke Control Systems CFR(s): NFPA 101 Engineered Smoke Control Systems When installed, engineered smoke control systems are tested in accordance with established engineering principles. Test documentation is maintained on the premises. 20.7.7.1 through 20.7.7.3, 21.7.7.1 through 21.7.7.3 This STANDARD is not met as evidenced by: . Based on review of documentation and interview, the facility failed to maintain the atrium smoke evacuation system per requirements of: 2012 NFPA 101, 21.7.7, 21.7.6, and 4.6.12 2011 NFPA 92, 8.6 This deficiency could affect approximately 20 occupants. Findings include: On 11/14/2019, during a tour of the facility from 8:00 am to 4:45 pm, the facility failed to provide documentation of the periodically testing of the smoke evacuation system in the atrium. A member of the maintenance staff was present when this deficiency was identified. . |
| K0918 | Essential Electrical Systems – Generator or Alternate Source CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This STANDARD is not met as evidenced by: . Based on review of documentation and interview, the facility failed to maintain the diesel generator's fuel per the requirements of: 2012 NFPA 99, 6.4.4.1.1.3, and 6.5.4.2 2010 NFPA 110, 1.3, and 8.3.8 This deficiency could affect approximately 25 occupants. Findings include: On 11/14/2019, during a tour of the facility from 8:00 am to 4:45 pm, the facility failed to provide documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards. A member of the maintenance staff was present when this deficiency was identified. . |
| K0929 | Gas Equipment – Precautions for Handling Oxygen CFR(s): NFPA 101 Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99). 11.6.2 (NFPA 99) This STANDARD is not met as evidenced by: . Based on review of documentation and interview, the facility failed to maintain the oxygen cylinders and manifolds per the requirements of: 2012 NFPA 99, 11.6.2, and CGA G-4, Oxygen This deficiency could affect approximately 50 occupants. Findings include: On 11/14/2019, during the review of documentation from 8:00 am to 4:45 pm, the facility failed to provide documentation on handling and the protection of oxygen cylinders and manifolds. A member of the maintenance staff was present when this deficiency was identified. |