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 01/03/2024
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)
K0000 K3 Building: 0101
K6 Plan Approval: 1984, 2009, 04/14/2016
K7 Survey Under: 2012 Existing
K8 ASC
Generator #1: Diesel, Taylor 75 kW (installed 2007)
Generator #2: Diesel, Generac 80 kW (installed 2015)
FACP: GE EST Quickstart (installed 08/2009)
Locking Devices: None
Smoke Detection: Complete
Case Load: 1200 a Month





Type of Structure: 1984 two story unprotected noncombustible, Type II(000), renovated in 2009. 2009 two story unprotected noncombustible, Type II(000) space converted from business occupancy. 04/14/2016 two story unprotected noncombustible, Type II(000) space converted from business occupancy. The facility has a complete automatic sprinkler system. The facility has an FM-200 automatic sprinkler system in the 2nd floor Records Room.





During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 416.44(b) were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel.



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