| 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) |
| 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 and interview, 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 Findings include: On 09/17/2019, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed an approximately 2" unsealed conduit with multiple gray wires above the ceiling on both sides of the smoke barrier in Hall 8 (east side of facility) near the Laundry Room. A member of the maintenance staff was present when this deficiency was identified. . |