| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001011 | (X3) Date Survey Completed 12/06/2023 |
| Name of Provider or Supplier Gadsden Surgery Center, Ltd | Street Address, City, State 418 South 5th Street, Gadsden, 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 / 1993 K7 Survey Under: 2012 Existing K8 ASC Generator: One Diesel, Caterpillar 150 kW (installed 1985) FACP: GE, EST (installed ?) Smoke Detection: Complete Building Sq. Ft.: 13,500 Census: Averages 20 cases a day Type of Structure: 1984/1993 One story unprotected Type II(000). The facility does not have an automatic sprinkler system. Facility has access-controlled egress doors. 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 Surveyors while accompanied by the facility maintenance personnel. . |
| 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 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 This deficiency affects the entire facility. Findings include: During review of the documentation, the facility failed to provide a smoke detector sensitivity test report completed within the past two years. The facility failed to provide documentation of the last smoke detector sensitivity test report. 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 observation, the facility failed to provide a remote manual stop station for the emergency generator per the requirements of: 2012 NFPA 101, 21.2.9.1, and 7.9.2.4 2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1 This deficiency affects 1 of 1 generators. Findings include: During a tour of the facility, the facility failed to provide a labeled, remote manual stop station for the 1985 Level 1 emergency generator. This was required when this generator was installed. A member of the maintenance staff was present when this deficiency was identified. |