| 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) |
| K0918 | Essential Electrical Systems – Generator or Alternate Source CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This STANDARD is not met as evidenced by: Based on review of documentation, the facility failed to maintain the two emergency generators per the requirements of: 2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3 2012 NFPA 101, 21.2.9.1, and 7.9.2.4 2010 NFPA 110, 8.3.7.1, 1.3, and 8.3.8 This deficiency affects two of two generators. Findings include: During the review of the documentation, the facility failed to provide documentation on both of the emergency generators for the following: 1. Performing monthly conductance or electrolyte specific gravity testing on the generator’s batteries for the past 12 months 2. A fuel quality test performed within the past twelve months using tests approved by ASTM standards A member of the maintenance staff was present when this deficiency was identified. . |