| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001010 | (X3) Date Survey Completed 09/18/2019 |
| Name of Provider or Supplier The Southern Alabama Surgery Center, Llc | Street Address, City, State 2800 Ross Clark Circle, Suite 3, Dothan, 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: 1984, 2009, 04/14/2016 K7 Survey Under: 2012 Existing K8 ASC Generator #1: Diesel, Taylor 75 kW (installed 2007) Generator #2: Diesel, Generac 80 kW (installed 2015) FACP: GE EST Quickstart (installed 08/2009) Locking Devices: None Smoke Detection: Complete Case Load: 2000 a Month Type of Structure: 1984 two story unprotected noncombustible, Type II(000), renovated in 2009. 2009 two story unprotected noncombustible, Type II(000) space converted from business occupancy. 04/14/2016 two story unprotected noncombustible, Type II(000) space converted from business occupancy. 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 as evidenced by the following deficiencies of NFPA 101 Life Safety Code (LSC) and codes referenced by the LSC, as observed by the LS Surveyors while accompanied by the facility maintenance personnel. . |
| K0131 | Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Ambulatory Health Care Facilities Multiple occupancies shall be in accordance with 6.1.14. Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following: * The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access. * They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating. Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following: * Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab. * Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches. * Doors are self-closing and are kept in the closed position, except when in use. * Windows in the barriers are of fixed fire window assemblies per 8.3. Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served. 20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44 This STANDARD is not met as evidenced by: . Based on observation and interview, the facility failed to maintain the tenant/occupancy barrier between the ASC and the Business Occupancy per the requirements of: 2012 NFPA 101, 21.3.7.1 (1) On 09/17/2019, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed an unsealed penetration between the 4 hour fire rated barrier and the corrugated deck between the 1st and 2nd Floor of the ASC at beds 2 and 3 in the existing recovery area on the 1st floor. This barrier separates the ASC from the Business Occupancy. A member of the maintenance staff was present when this deficiency was identified. . |
| K0161 | Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height Building construction type and stories meet Table 20.1.6.1 or Table 21.1.6.1, respectively. Construction Type 1 I (442), I (332), II (222), Any number of stories II (111), III (211), IV (2HH), non-sprinklered or sprinklered V (111) 2 II (000), III (200), V (000) One story non-sprinklered Any number of stories sprinklered Any level below the level of exit discharge shall be separated by Type II (111), Type III (211), or Type V (111) construction unless both of the following are met: 1. Such levels are under the control of the ambulatory health care occupancy. 2. Hazardous spaces are protected per section 8.7. Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 20.3.5 or 21.3.5, respectively) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. 20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2 This STANDARD is not met as evidenced by: . Based on observation and interview, the facility failed to provide a complete automatic sprinkler system per the requirements of: 2012 NFPA 101, 21.1.6.1, and Table 21.1.6.1 Findings include: On 09/17/2019, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed the triangular shaped Counseling Room in the corner of the GI Hall in the 2016 space did not have automatic sprinkler coverage. A member of the maintenance staff was present when this deficiency was identified. . |
| 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 and interview, the facility failed to install an Alcohol-Based Hand-Rub (ABHR) Dispenser per the requirements of: 2012 NFPA 101, 21.3.2.6 (8) Findings include: On 09/18/2019, during a tour of the facility from 6:00 am to 12:30 pm, the surveyor observed an ABHR dispenser was mounted directly above a light switch (ignition source) in the following locations: 1. Operating Room 5 2. Operating Room 6 A member of maintenance staff was present when this deficiency was found. . |
| 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 and interview, the facility failed to maintain the smoke detectors per the requirements of: 2012 NFPA 101, 21.3.4.1, and 9.6.1.3 2010 NFPA 72, 14.4.5.3.2 Findings include: On 09/18/2019, during a tour of the facility from 6:00 am to 12:30 pm, the facility failed to provide a smoke detector sensitivity test report completed within the past two years. The last documented sensitivity test was not available. 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 and interview, the facility failed to maintain the automatic sprinkler system per the requirements of: 2012 NFPA 101, 9.7.1.2 2010 NFPA 13, 6.2.9.6, 8.6.4.1.1.1, 8.5.4.2, and 8.1.1(3) Findings include: On 09/17/2019, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed the following: 1. The sprinkler cabinet was without a sprinkler wrench 2. An approximately 1' x 2' ceiling tile was missing in the Telecom Room off of Hall 8 on the east side of the facility 3. The triangular shaped Counseling Room in the corner of the G.I. Hall in the new section did not have automatic sprinkler coverage A member of the 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 observation and interview, the facility failed to maintain the automatic sprinkler system per the requirements of: 2012 NFPA 101, 9.7.5 2011 NFPA 25, 5.2.2.2 Findings include: On 09/17/2019, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed a supply air duct coil (external load) resting on the automatic sprinkler pipe above the ceiling near beds 2 and 3 in the existing recovery area. 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 and interview, 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 Findings include: On 09/17/2019, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed an approximately 2" unsealed conduit with multiple gray wires above the ceiling on both sides of the smoke barrier in Hall 8 (east side of facility) near the Laundry Room. A member of the maintenance staff was present when this deficiency was identified. . |
| K0511 | Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2 This STANDARD is not met as evidenced by: . Based on observation and interview, the facility failed to maintain the electrical wiring and equipment per the requirements of: 2012 NFPA 101, 21.5.1, and 9.1.2 2011 NFPA 70, 314.28(3)(C) Findings include: On 09/18/2019, during a tour of the facility from 6:00 am to 12:30 pm, the surveyor observed a 4"x4" electrical junction box above the ceiling was missing its cover plate at Recovery beds 2 and 3. A member of the maintenance staff was present when this deficiency was identified. . |
| K0521 | HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 20.5.2.1, 21.5.2.1, 9.2 This STANDARD is not met as evidenced by: . Based on review of documentation and interview, the facility failed to maintain the dampers (smoke/fire/ceiling) per the requirements of: 2012 NFPA 101, 21.5.2.1, and 9.2.1 2010 NFPA 80, 19.4, and 19.5 2012 NFPA 90A, 5.4.8.1 2010 NFPA 80, 19.4.1.1 Findings include: On 09/17/2019, during a tour of the facility from 10:30 am to 4:30 pm, the facility failed to provide documentation of testing the fire dampers within the past 6 years. A member of the maintenance staff was present when this deficiency was identified. . |
| K0923 | Electrical Equipment – Ground-Fault Circuit-Interrupter Protection CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage *Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. *Greater than 300 but less than 3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating. *Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This STANDARD is not met as evidenced by: . Based on observation and interview, the facility failed to maintain the oxygen cylinders per the requirements of: 2012 NFPA 99, 11.6.2.3 (11) On 09/18/2019, during a tour of the facility from 6:00 am to 12:30 pm, the surveyor observed one unsecured oxygen cylinder outside in the Medical Gas Room. A member of the maintenance staff was present when this deficiency was identified. |