| 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) |
| 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 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. . |