Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 01C0001008 (X3) Date Survey Completed 10/11/2023
Name of Provider or Supplier Birmingham Outpatient Surgery Center, Ltd Street Address, City, State 2720 University Boulevard, Birmingham, 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)
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 an Alcohol-Based Hand-Rub (ABHR) Dispenser per the requirements of:





2012 NFPA 101, 21.3.2.6 (8)





This deficiency affects 1 of 6 smoke compartments.


Findings include:





During a tour of the facility, the surveyor observed an ABHR Dispenser was mounted 2’-0" directly above a sconce night light (ignition source) on the second floor in "Patient Room 1/3".





A member of maintenance staff was present when this deficiency was identified.


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