| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 65C0001001 | (X3) Date Survey Completed 02/08/2019 |
| Name of Provider or Supplier Hafa Adai Specialist Group, Llp | Street Address, City, State Sunflower Villa, 280 Pale San Vitores, Tamuning, GU | |
| 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) |
| K0131 | Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Ambulatory Health Care Facilities Multiple occupancies shall be in accordance with 6.1.14. Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following: * The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access. * They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating. Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following: * Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab. * Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches. * Doors are self-closing and are kept in the closed position, except when in use. * Windows in the barriers are of fixed fire window assemblies per 8.3. Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served. 20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44 This STANDARD is not met as evidenced by: Based on observation and interview Hafa Adai Specialty Group is not maintaining the required separation between its business occupancy and its ambulatory health care occupancy. Failure to maintain the required separation exposes staff and patients, who could be under general anesthesia, to increased risk from fire in the business occupancy portion of the facility. Findings include: On February 8, 2019 at approximately 2PM the space above the suspended ceiling in the recovery room area was observed. The CMS Health Surveyor and the maintenance employee were present. It was found that a barrier extended from the floor slab to the second story slab around the operating room. No such barrier was observed separating the recovery room from the hallway leading to the patient examination rooms. Also observed was the space above the suspended ceiling next to the door between the waiting area and the hallway leading to the patient examination rooms. No such barrier was in place to separate these two areas. The maintenance employee was familiar with this configuration and agreed with the observation. |