| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001013 | (X3) Date Survey Completed 07/25/2018 |
| Name of Provider or Supplier Op Surg Ctr, Inc And Surgicare Of Huntsville, Inc | Street Address, City, State 721 Madison Street, Huntsville, 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) |
| K0321 | Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas must meet one of the following: *Contain 1 hour rated enclosure when non-sprinklered *Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7 This STANDARD is not met as evidenced by: . Based on observation and interview, this building failed to ensure that the hazardous room doors were positive latching with the self-closing devices per the requirements of: 2012 NFPA 101, 21.3.2 42 CFR 483.90 (a) (1) (ii) This deficiency could affect 1 of 7 smoke compartments. Findings include: On 07/24/2018 during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed the door to the Nitrogen Cylinders Manifolds Room (hazardous room) located on the fourth floor, failed to positive latch with the self-closing device. A member of the maintenance staff was present, when this deficiency was identified. . |