Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
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)
K0211 Means of Egress - General
CFR(s): NFPA 101

Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1


This STANDARD is not met as evidenced by:
Based on observation and interview the facility failed to maintain a means of egress free of all obstructions or impediments. Failure to do so could delay or prevent the prompt evacuation of staff.



Findings include:



1. On January 31, 2019, between 1030AM and 1215PM, during a walk-through of the facility with the facility's maintenance employee the approximately 12 foot corridor between the bathroom and the billing office was observed to being used as a storage area for office documents and empty cardboard boxes. These were stored on a cart against one wall and reached a height of approximately 6 feet. This reduced the corridor width to approximatley 22 inches. The maintenance employee confirmed that the corridor was obstructed. This could affect all of the facility's staff.





2. On January 31, 2019, between 1030AM and 1215PM, during a walk-through of the facility with the facility's maintenance employee it was observed that the exit discharge located in the employee lounge area was obstructed by electronic devices The maintenance employee said the eelectronic devices had been placed at this location for eventual disposal. This could affect all of the facility's patients and staff.