| 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) |
| 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 provide a fire suppression system 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, 9.7.7, and 9.7.8 2010 NFPA 13, 8.15.7.1 This deficiency affects 2 of 3 combustible fabric awnings. Findings include: During a tour of the facility, the surveyor observed the following unsprinklered combustible overhangs (fabric awnings), and the facility was unable to provide documentation on the fire retardancy of these awnings. Both awnings were 6'-0" x 6'-6": 1. One outside the East Stair Exit 2. One outside the West Stair Exit A member of the maintenance staff was present when this deficiency was identified. . |