| 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) |
| 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 and interview, the facility failed to maintain the smoke detectors per the requirements of: 2012 NFPA 101, 21.3.4.1, and 9.6.1.3 2010 NFPA 72, 14.4.5.3.2 Findings include: On 09/18/2019, during a tour of the facility from 6:00 am to 12:30 pm, the facility failed to provide a smoke detector sensitivity test report completed within the past two years. The last documented sensitivity test was not available. A member of the maintenance staff was present when this deficiency was identified. . |