| 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) |
| K0353 | Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: Based on review of documentation, the facility failed to maintain the automatic sprinkler system for the past 12 months per the requirements of: 2012 NFPA 101, 2012 NFPA 101, 4.6.1.2, 4.6.12.3, 4.6.12.4, 4.6.12.5, 9.7.5, 9.7.7, and 9.7.8 2011 NFPA 25, Table 5.1.1.2 This deficiency affects two of the four quarterly inspections. Findings include: During the review of the documentation, the facility failed to provide all of the quarterly automatic sprinkler inspection records for the past 12 months. Only two reports dated 02/22/2023 and 05/24/2023 were provided. A member of the maintenance staff and the administrator were present when this deficiency was identified. . |