| 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) |
| 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 and interview, this building failed to maintain the standpipe riser gauges per the requirements of: 2012 NFPA 101, 21.3.4.1, and 9.6.1.3 2011 NFPA 25, 6.3.4.1 Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed that the standpipe riser gauges in both East and West Stairs had not been calibrated or replaced within the past 5 years. The gauges were last calibrated on 08/07/2012 per documentation and interview. A member of the maintenance staff was present when this deficiency was identified. . |