Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 01C0001008	(X3) Date Survey Completed 10/11/2023
Name of Provider or Supplier Birmingham Outpatient Surgery Center, Ltd	Street Address, City, State 2720 University Boulevard, Birmingham, 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: 07/05/1984 K7 Survey Under: 2012 Existing K8 ASC Generator: Diesel, Caterpillar 150 kW (installed 2021) Locking Devices: N/A FACP: Siemens, Firefinder XLS (installed 2010) Smoke Detection: Complete Surgeries per day: 40 Type of Structure: 1984 Two story with basement unprotected noncombustible, Type II(000). 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) 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. .
K0325	Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: o Corridor is at least 6 feet wide. o Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols. o Dispensers shall have a minimum of 4-foot horizontal spacing. o Not more than an aggregate of 10 gallons of fluid or 1135 ounces of aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room. o Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30. o Dispensers are not installed within 1 inch of an ignition source. o If floor is carpeted, the building is fully sprinkler protected. o ABHR does not exceed 95% alcohol. o Operation of the dispenser shall comply with Section 20.3.2.6(11) or 21.3.2.6(11). o ABHR is protected against inappropriate access. 21.3.2.6, 8.7.3.1, CFR 416.44 This STANDARD is not met as evidenced by: Based on observation, the facility failed to install an Alcohol-Based Hand-Rub (ABHR) Dispenser per the requirements of: 2012 NFPA 101, 21.3.2.6 (8) This deficiency affects 1 of 6 smoke compartments. Findings include: During a tour of the facility, the surveyor observed an ABHR Dispenser was mounted 2’-0" directly above a sconce night light (ignition source) on the second floor in "Patient Room 1/3". A member of maintenance staff was present when this deficiency was identified. .
K0345	Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm Systems - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This STANDARD is not met as evidenced by: Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of: 2012 NFPA 101, 21.3.4.1, and 9.6.1.3 2010 NFPA 72, Table 14.3.1(9)(h) This deficiency affects all smoke detectors. Findings include: During the review of documentation, the facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months. 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 a fire suppression system per the requirements of: 2012 NFPA 101, 4.6.1.2, 4.6.12.3, 4.6.12.4, 4.6.12.5, 9.7.1, 9.7.7, and 9.7.8 2010 NFPA 13, 8.15.7.1 This deficiency affects 2 of 3 combustible fabric awnings. Findings include: During a tour of the facility, the surveyor observed the following unsprinklered combustible overhangs (fabric awnings), and the facility was unable to provide documentation on the fire retardancy of these awnings. Both awnings were 6'-0" x 6'-6": 1. One outside the East Stair Exit 2. One outside the West Stair Exit A member of the maintenance staff was present when this deficiency was identified. .
K0372	Subdivision of Building Spaces – Smoke Barrier Construction CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 21.3.7.5, 21.3.7.6, 8.5 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 2 of 6 smoke compartments. Findings include: During a tour of the facility, the surveyor observed the following above the ceiling, penetrating both sides of the smoke barrier between the Basement Waiting Room and Sterile Supply: A 4" unsealed conduit A 3/8" MC cable 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, the facility failed to maintain the testing of the emergency generator and failed to provide a remote manual stop station per the requirements of: 2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3 2012 NFPA 101, 21.2.9.1, and 7.9.2.4 2010 NFPA 110, 8.3.7.1 This deficiency affects 1 of 1 generator. Findings include: During the documentation review, the facility failed to provide documentation of performing monthly conductance or electrolyte specific gravity testing on the facility’s emergency generator’s battery for the past 12 months. A member of the maintenance staff was present when this deficiency was identified. .