| 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) |
| 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 and interview, the facility failed to install an Alcohol-Based Hand-Rub (ABHR) Dispenser per the requirements of: 2012 NFPA 101, 21.3.2.6 (8) Findings include: On 09/18/2019, during a tour of the facility from 6:00 am to 12:30 pm, the surveyor observed an ABHR dispenser was mounted directly above a light switch (ignition source) in the following locations: 1. Operating Room 5 2. Operating Room 6 A member of maintenance staff was present when this deficiency was found. . |