| 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) |
| 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, the facility failed to maintain a smoke barrier 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 This deficiency affects 1 of 5 smoke barriers. Findings include: During a tour of the facility, the surveyor observed a 1/2" unsealed EMT conduit (used as a chase) with multiple white cables above the ceiling, over the cross-corridor doors between the Pre-op and OR corridors on both sides of the smoke barrier. A member of the maintenance staff was present when this deficiency was identified. . |