Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 01C0001013	(X3) Date Survey Completed 07/25/2018
Name of Provider or Supplier Op Surg Ctr, Inc And Surgicare Of Huntsville, Inc	Street Address, City, State 721 Madison Street, Huntsville, 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: 0203 K6 Plan Approval:1985 K7 Survey Under: 2012 Existing K8 ASC Generator: One Diesel, Kohler 1280 kW FACP: Faraday MPC-7000 Locking Devices: Full Time Magnetic Smoke Detection: Complete Case Load: 2200 a Month Type of Structure: One story unprotected wood frame, Type V (000). This building has a complete automatic sprinkler system. The unprotected wood roof deck was observed above the ceiling in the egress corridor outside of OR's 6 and 7, and in the main corridor between the 4 hour fire wall and the OR Area. During a routine recertification survey conducted on this date, this building was found not in compliance with 42 CFR 416.44 (b) as evidenced by the following deficiencies of NFPA 101 Life Safety Code (LSC) and codes referenced by the LSC, as observed by the LSC Surveyors while accompanied by the facility maintenance personnel. . . K3 Building: 0303 K6 Plan Approval:1985 K7 Survey Under: 2012 Existing K8 ASC Generator: One Diesel, Kohler 1280 kW FACP: Faraday MPC-7000 Locking Devices: Full Time Magnetic Smoke Detection: Complete Case Load: 2200 a Month Type of Structure: Four story protected noncombustible, Type II (222). This building has a complete automatic sprinkler system, except in the Electrical Rooms, see 2010 NFPA 13, 8.15.10.3. During a routine recertification survey conducted on this date, this building was found not in compliance with 42 CFR 416.44 (b) as evidenced by the following deficiencies of NFPA 101 Life Safety Code (LSC) and codes referenced by the LSC, as observed by the LSC Surveyors while accompanied by the facility maintenance personnel. . . K3 Building: 0103 K6 Plan Approval:1985 K7 Survey Under: 2012 Existing K8 ASC Generator: One Diesel, Kohler 1280 kW FACP: Faraday MPC-7000 Locking Devices: Full Time Magnetic Smoke Detection: Complete Case Load: 2200 a Month Type of Structure: One story unprotected wood frame, Type V (000). This building has a complete automatic sprinkler system. The unprotected wood was observed above the ceiling in the Doctors' Lounge Corridor. During a routine recertification survey conducted on this date, this building was found not in compliance with 42 CFR 416.44 (b) as evidenced by the following deficiencies of NFPA 101 Life Safety Code (LSC) and codes referenced by the LSC, as observed by the LSC Surveyors while accompanied by the facility maintenance personnel. .
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 and interview, this building failed to ensure that the hazardous room doors were positive latching with the self-closing devices per the requirements of: 2012 NFPA 101, 21.3.2 42 CFR 483.90 (a) (1) (ii) This deficiency could affect 1 of 7 smoke compartments. Findings include: On 07/24/2018 during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed the door to the Nitrogen Cylinders Manifolds Room (hazardous room) located on the fourth floor, failed to positive latch with the self-closing device. A member of the maintenance staff was present, when this deficiency was identified. .
K0344	Fire Alarm - Control Functions CFR(s): NFPA 101 Fire Alarm - Control Functions The fire alarm automatically activates required control functions and is provided with an alternative power supply in accordance with NFPA 72. 20.3.4.4, 21.3.4.4 This STANDARD is not met as evidenced by: . Based on observation and interview, this building failed to maintain the fire alarm control functions per the requirements of: 2012 NFPA 101, 21.3.4.4, and 9.6.5 2010 NFPA 72, 21.8, and 21.9 This deficiency could affect all occupants. Findings include: On 07/25/2018, during a tour of the facility from 7:00 am to 11:30 am, the surveyor observed the following doors failed to automatically unlock upon loss of primary power to the fire alarm system: 1. The electric locked exterior egress doors located throughout the entire building 2. The magnetic door holders located throughout the entire building A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain the fire alarm control functions per the requirements of: 2012 NFPA 101, 21.3.4.4, and 9.6.5 2010 NFPA 72, 21.8, and 21.9 This deficiency could affect all occupants. Findings include: On 07/25/2018, during a tour of the facility from 7:00 am to 11:30 am, the surveyor observed the following doors failed to automatically unlock upon loss of primary power to the fire alarm system: 1. The electric locked exterior egress doors located throughout the entire building 2. The magnetic door holders located throughout the entire building A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain the fire alarm control functions per the requirements of: 2012 NFPA 101, 21.3.4.4, and 9.6.5 2010 NFPA 72, 21.8, and 21.9 This deficiency could affect all occupants. Findings include: On 07/25/2018, during a tour of the facility from 7:00 am to 11:30 am, the surveyor observed the following doors failed to automatically unlock upon loss of primary power to the fire alarm system: 1. The electric locked exterior egress doors located throughout the entire building 2. The magnetic door holders located throughout the entire building A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain the fire alarm control functions per the requirements of: 2012 NFPA 101, 21.3.4.4, and 9.6.5 2010 NFPA 72, 21.8, and 21.9 This deficiency could affect all occupants. Findings include: On 07/25/2018, during a tour of the facility from 7:00 am to 11:30 am, the surveyor observed the following doors failed to automatically unlock upon loss of primary power to the fire alarm system: 1. The electric locked exterior egress doors located throughout the entire building 2. The magnetic door holders located throughout the entire building A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain the fire alarm control functions per the requirements of: 2012 NFPA 101, 21.3.4.4, and 9.6.5 2010 NFPA 72, 21.8, and 21.9 This deficiency could affect all occupants. Findings include: On 07/25/2018, during a tour of the facility from 7:00 am to 11:30 am, the surveyor observed the following doors failed to automatically unlock upon loss of primary power to the fire alarm system: 1. The electric locked exterior egress doors located throughout the entire building 2. The magnetic door holders located throughout the entire building A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain the fire alarm control functions per the requirements of: 2012 NFPA 101, 21.3.4.4, and 9.6.5 2010 NFPA 72, 21.8, and 21.9 This deficiency could affect all occupants. Findings include: On 07/25/2018, during a tour of the facility from 7:00 am to 11:30 am, the surveyor observed the following doors failed to automatically unlock upon loss of primary power to the fire alarm system: 1. The electric locked exterior egress doors located throughout the entire building 2. The magnetic door holders located throughout the entire building A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain the fire alarm control functions per the requirements of: 2012 NFPA 101, 21.3.4.4, and 9.6.5 2010 NFPA 72, 21.8, and 21.9 This deficiency could affect all occupants. Findings include: On 07/25/2018, during a tour of the facility from 7:00 am to 11:30 am, the surveyor observed the following doors failed to automatically unlock upon loss of primary power to the fire alarm system: 1. The electric locked exterior egress doors located throughout the entire building 2. The magnetic door holders located throughout the entire building 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 and interview, this building failed to maintain the standpipe riser gauges per the requirements of: 2012 NFPA 101, 21.3.4.1, and 9.6.1.3 2011 NFPA 25, 6.3.4.1 Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed that the standpipe riser gauges in both East and West Stairs had not been calibrated or replaced within the past 5 years. The gauges were last calibrated on 08/07/2012 per documentation and interview. 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, this building failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5 , 8.5.1, and 8.5.6.2 This deficiency could affect two smoke compartments. Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed white and red wires going through an unsealed 1/2" penetration in a 4 hour barrier that separated building 1 and building 2. The penetration was located in the small corridor by OR 7. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed an unsealed penetration around a support beam located on the 3rd floor just to the left of the single service elevator. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5 , 8.5.1, and 8.5.6.2 This deficiency could affect two smoke compartments. Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed white and red wires going through an unsealed 1/2" penetration in a 4 hour barrier that separated building 1 and building 2. The penetration was located in the small corridor by OR 7. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 This deficiency could affect two smoke compartments. Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed white and red wires going through an unsealed 1/2" penetration in a 4 hour barrier that separates building 0103 and building 0203. The penetration was located on the other side of the rated door near the small corridor by OR 7. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed an unsealed penetration around a support beam located on the 3rd floor just to the left of the single service elevator. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 This deficiency could affect two smoke compartments. Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed white and red wires going through an unsealed 1/2" penetration in a 4 hour barrier that separates building 0103 and building 0203. The penetration was located on the other side of the rated door near the small corridor by OR 7. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed an unsealed penetration around a support beam located on the 3rd floor just to the left of the single service elevator. 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, this building failed to maintain the electrical wiring and equipment per the requirements of: 2012 NFPA 101, 21.5.1.1, and 9.1.2 2011 NFPA 70, 406.6 Findings include: On 7/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed a cover plate not properly installed onto a receptacle. The in use receptacle was located in the 3rd floor Kitchen between the fryer and the stove. A member of the maintenance staff corrected the deficiency, once it was pointed out. A member of the maintenance staff was present when this deficiency was identified.