| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001013 | (X3) Date Survey Completed 06/11/2025 |
| 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: 05/1985 K7 Survey Under: 2012 Existing K8 ASC Generator: One Diesel, Kohler 1280 kW (installed 2008 with remote manual stop station) FACP: Siemens FC922-US (installed 01/2024) Locking Devices: Full Time Magnetic Smoke Detection: Complete Case Load: 2200 a Month Type of Structure: 1985 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. . |
| K0211 | Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 21.2.1, and 7.2.1.9.1.3 This deficiency affects 1 of 6 powered doors. Findings include: During a tour of the facility, the surveyor observed the powered egress door leaves between the West Hall and the West Operating Room Suite did not have signs on the egress sides that reads: "IN EMERGENCY, PUSH TO OPEN". 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 1 hazardous room. Findings include: During a tour of the facility, the surveyor observed an unsealed penetration through the ceiling of the South Riser Room of a 4" PVC conduit used as an exhaust for 3 gas, tankless water heaters. A member of maintenance staff was present when this deficiency was identified. . |
| K0342 | Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit and 200 feet travel distance is not exceeded. 20.3.4.2, 21.3.4.2, 9.6.2 This STANDARD is not met as evidenced by: Based on review of documentation, the facility failed to provide the code required tamper switches (electronic supervisory signal) for the automatic sprinkler system per the requirements of: 2012 NFPA 101, 4.6.1.2, 4.6.12, and 9.7.2.1 2010 NFPA 72, 10.7.4, and 10.16.2 This deficiency affects the whole facility. Findings include: During a tour of the facility, the surveyor observed the following in the sprinkler control valve pit: 1. One of two valves, the existing non-code approved tamper switch was a plug-in-type tamper switch 2. The other valve did not have a tamper switch. It appeared to the surveyor that the valve had a switch in the past but has been removed. A member of the maintenance staff and the administrator were present, when this deficiency was identified. . Findings include: During a tour of the facility, the surveyor observed the following in the sprinkler control valve pit: 1. One of two valves, the existing non-code approved tamper switch was a plug-in-type tamper switch 2. The other valve did not have a tamper switch. It appeared to the surveyor that the valve had a switch in the past but has been removed. A member of the maintenance staff and the administrator were present, when this deficiency was identified. . Findings include: During a tour of the facility, the surveyor observed the following in the sprinkler control valve pit: 1. One of two valves, the existing non-code approved tamper switch was a plug-in-type tamper switch 2. The other valve did not have a tamper switch. It appeared to the surveyor that the valve had a switch in the past but has been removed. A member of the maintenance staff and the administrator were 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 post a list of sprinklers installed in the property at the sprinkler cabinets per the requirements of: 2012 NFPA 101, 4.6.1.2, 4.6.12.3, 4.6.12.4, 4.6.12.5, 9.7.1.1, and 9.7.7 2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1 This deficiency affects the complete sprinkler system. Findings include: During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at both of the riser sprinkler cabinet locations. The list shall include the following: (1) Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating (2) General description (3) Quantity of each type to be contained in the cabinet (4) Issue or revision date of the list 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 review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of: 2012 NFPA 101, 9.7.5, 9.7.7, and 9.7.8 2011 NFPA 25, 5.3.1.1.1.3 and 5.3.1.2 This deficiency affects the complete facility sprinkler system. Findings include: During a tour of the facility, the facility failed to provide documentation that the 2007 quick response, dry sprinklers located in the walk-in cooler and freezer had been replaced or a representative sample tested within 10 years of installation. 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, the facility failed to maintain the smoke and fire dampers per the requirements of: 2012 NFPA 101, 21.5.2.1, and 9.2.1 2012 NFPA 90A, 5.4.8.1, and 5.4.8.2 2010 NFPA 80, 19.4, and 19.5 2010 NFPA 105, 6.5.2, 6.5.11, and 6.5.12 This deficiency affects all smoke and fire dampers. Findings include: During a tour of the facility, the facility failed to provide documentation of testing the smoke and fire dampers within the past 4 years. A member of the maintenance staff was present when this deficiency was identified. . |
| K0920 | Electrical Equipment – Power Cords and Extension Cords CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain the electrical equipment per the requirements of: 2012 NFPA 99, 10.2.3.6, and 10.2.4 2011 NFPA 70, 400.8 S&C: 14-46-LCS This deficiency affects 1 of 3 Buildings. Findings include: During a tour of the facility, the surveyor observed the permanent use of a temporary electrical extension cord to supply an outdoor power strip and two LED flood light fixtures. The cord, power strip and light fixtures were located in a planter area next to the front of the building between the Main Entrance door and the Discharge door on the North side of the building. 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, the facility failed to maintain the oxygen cylinders per the requirements of: 2012 NFPA 99, 11.6.5.4 This deficiency affects all of the back-up oxygen cylinders. Findings include: During a tour of the facility, the facility failed to protect the outside back-up oxygen cylinders in the storage area against continuous exposure to direct rays of the sun where extreme temperatures prevail. A member of the maintenance staff was present when this deficiency was identified. . |