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 01C0001010 (X3) Date Survey Completed 09/18/2019
Name of Provider or Supplier The Southern Alabama Surgery Center, Llc Street Address, City, State 2800 Ross Clark Circle, Suite 3, Dothan, 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)
K0161 Building Construction Type and Height
CFR(s): NFPA 101

Building Construction Type and Height Building construction type and stories meet Table 20.1.6.1 or Table 21.1.6.1, respectively. Construction Type 1 I (442), I (332), II (222), Any number of stories II (111), III (211), IV (2HH), non-sprinklered or sprinklered V (111) 2 II (000), III (200), V (000) One story non-sprinklered Any number of stories sprinklered Any level below the level of exit discharge shall be separated by Type II (111), Type III (211), or Type V (111) construction unless both of the following are met: 1. Such levels are under the control of the ambulatory health care occupancy. 2. Hazardous spaces are protected per section 8.7. Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 20.3.5 or 21.3.5, respectively) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. 20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2


This STANDARD is not met as evidenced by:
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Based on observation and interview, the facility failed to provide a complete automatic sprinkler system per the requirements of:



2012 NFPA 101, 21.1.6.1, and Table 21.1.6.1



Findings include:



On 09/17/2019, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed the triangular shaped Counseling Room in the corner of the GI Hall in the 2016 space did not have automatic sprinkler coverage.



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



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