| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001010 | (X3) Date Survey Completed 01/03/2024 |
| 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: 1200 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. The facility has an FM-200 automatic sprinkler system in the 2nd floor Records Room. 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. . |
| 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, 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) This deficiency affects one room in the Ambulatory Surgery Center. Findings include: During a tour of the facility the surveyor observed an unsealed penetration of multiple purple cables in the 4-hour fire rated barrier on the 2nd floor between “Dr. Heersink's Storage Room” and the corridor in the Eye Center (above the ceiling, over the tenant separation doors). This barrier separates the Ambulatory Surgery Center from the Business Occupancy. A member of the maintenance staff was present when this deficiency was identified. . |
| 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, the facility failed to maintain a hazardous room per the requirements of: 2012 NFPA 101, 21.3.2, 39.3.2.1 and 8.7 This deficiency affects one hazardous room. Findings include: During a tour of the facility, the surveyor observed an unsealed penetration of a 2" conduit used as a chase for multiple gray, yellow, orange and blue cables on both sides of the 1 hour rated wall between the Medical Gas Storage Room and the Employee Back Hall. A member of 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, the facility failed to install Alcohol-Based Hand-Rub (ABHR) Dispensers per the requirements of: 2012 NFPA 101, 21.3.2.6 (8) This deficiency affects 1 of 12 Operating Rooms. Findings include: During a tour of the facility, the surveyor observed two ABHR Dispensers mounted 8” directly above two different light switches (ignition sources) in Operating Room 4. 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 the 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. . |
| 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, the facility failed to maintain the automatic sprinkler system for the past 12 months per the requirements of: 2012 NFPA 101, 2012 NFPA 101, 4.6.1.2, 4.6.12.3, 4.6.12.4, 4.6.12.5, 9.7.5, 9.7.7, and 9.7.8 2011 NFPA 25, Table 5.1.1.2 This deficiency affects two of the four quarterly inspections. Findings include: During the review of the documentation, the facility failed to provide all of the quarterly automatic sprinkler inspection records for the past 12 months. Only two reports dated 02/22/2023 and 05/24/2023 were provided. A member of the maintenance staff and the administrator were 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 a smoke barrier 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 1 of 5 smoke barriers. Findings include: During a tour of the facility, the surveyor observed a 1/2" unsealed EMT conduit (used as a chase) with multiple white cables above the ceiling, over the cross-corridor doors between the Pre-op and OR corridors on both sides of the smoke barrier. A member of the maintenance staff was present when this deficiency was identified. . |
| K0781 | Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies. Except, when used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 20.7.8, 21.7.8 This STANDARD is not met as evidenced by: Based on observation, the facility failed to prohibit a portable space heating device per the requirements of: 2012 NFPA 101, 21.7.8 This deficiency affects 1 of 7 smoke compartments. Findings include: During a tour of the facility, the surveyor observed a portable space heating device that was off, sitting on a laminate floor, between a wood desk and metal desk and plugged in to a power strip. This was not located in a patient sleeping smoke compartment. The facility was unable to provide documentation that the heating element did not exceeding 212 degrees. 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 two emergency generators 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, 1.3, and 8.3.8 This deficiency affects two of two generators. Findings include: During the review of the documentation, the facility failed to provide documentation on both of the emergency generators for the following: 1. Performing monthly conductance or electrolyte specific gravity testing on the generator’s batteries for the past 12 months 2. A fuel quality test 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. . |