| 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) |
| 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, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 2 of 6 smoke compartments. Findings include: During a tour of the facility, the surveyor observed the following above the ceiling, penetrating both sides of the smoke barrier between the Basement Waiting Room and Sterile Supply: A 4" unsealed conduit A 3/8" MC cable A member of the maintenance staff was present when this deficiency was identified. . |