| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001000 | (X3) Date Survey Completed 11/14/2023 |
| 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 requirements of 42 CFR, Subpart 416.44(b) - ASC were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. . |
| K0211 | Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1 This STANDARD is not met as evidenced by: . Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 21.2.1, 7.1.6.2, 7.1.6.3(1), and 7.1.10.1 This deficiency affects 1 means of egress. Findings include: During a tour of the facility, the surveyors observed the egress door from Pre-OP that leads into the Patients' Discharge Hall was blocked by two hospital beds, preventing the door from fully opening. A member of the maintenance staff was present when this deficiency was identified. . |
| K0351 | Sprinkler System - Installation CFR(s): NFPA 101 Sprinkler System - Installation Sprinkler systems (if installed) are installed per NFPA 13. Where more than two sprinklers are installed in a single area for protection, waterflow devices shall be provided to sound the building fire alarm system or to notify a constantly attended location such as a PBX, security office, or emergency room. 20.3.5.1, 20.3.5.2, 21.3.5.1, 21.3.5.2, 9.7.1.2, 9.7, NFPA 13 This STANDARD is not met as evidenced by: . Based on observation, the facility failed to provide an electronic supervising (tamper switch) for the backflow preventer valve for the automatic sprinkler system per the requirements of: 2012 NFPA 101, 21.3.5.1, and 9.7.2.1 2010 NFPA 72, 10.7.4, and 10.16.2 This deficiency affects the entire sprinkler system. Findings include: During a tour of the facility, the surveyor observed the backflow preventer valve for the automatic sprinkler system did not have an electronic supervising device (tamper switch) installed. A member of the maintenance staff and the administrator were present, when this deficiency was identified. . |
| K0908 | Gas and Vacuum Piped Systems – Central Supply System Alarms CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This STANDARD is not met as evidenced by: . Based on review of documentation, the facility failed to maintain the piped medical gas and vacuum systems per the requirements of: 2012 NFPA 99, 5.1.14.2.3 This deficiency affects all of the medical gas and vacuum systems. During a tour of the facility, the facility failed to provide documentation of the annual inspection for the piped medical gas and vacuum systems for the past 12 months. A member of the maintenance staff was present when this deficiency was identified. |