| 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) |
| 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 and interview, this building failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5 , 8.5.1, and 8.5.6.2 This deficiency could affect two 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 white and red wires going through an unsealed 1/2" penetration in a 4 hour barrier that separated building 1 and building 2. The penetration was located in the small corridor by OR 7. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed an unsealed penetration around a support beam located on the 3rd floor just to the left of the single service elevator. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5 , 8.5.1, and 8.5.6.2 This deficiency could affect two 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 white and red wires going through an unsealed 1/2" penetration in a 4 hour barrier that separated building 1 and building 2. The penetration was located in the small corridor by OR 7. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 This deficiency could affect two 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 white and red wires going through an unsealed 1/2" penetration in a 4 hour barrier that separates building 0103 and building 0203. The penetration was located on the other side of the rated door near the small corridor by OR 7. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed an unsealed penetration around a support beam located on the 3rd floor just to the left of the single service elevator. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 This deficiency could affect two 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 white and red wires going through an unsealed 1/2" penetration in a 4 hour barrier that separates building 0103 and building 0203. The penetration was located on the other side of the rated door near the small corridor by OR 7. A member of the maintenance staff was present when this deficiency was identified. . . Based on observation and interview, this building failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, and 8.5.6.2 Findings include: On 07/24/2018, during a tour of the facility from 11:45 am to 3:45 pm, the surveyor observed an unsealed penetration around a support beam located on the 3rd floor just to the left of the single service elevator. A member of the maintenance staff was present when this deficiency was identified. . |