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)
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 the facility failed to provide protection from areas in which combustible materials were being stored. Failure to do so could result in a fire spreading with more speed and intensity reducing the time required for safe evacuation of personnel and patients. This could affect personnel and patients in the operating room and the recovery room. The patients could potentially be under the effects of general anesthetics.



Findings include:



On February 1, 2019 during a walk-through of the facility, with the CMS Health Surveyor and the Operating Room Technician it was observed that in the laundry room a penetration in the wall, behind the washer and dryer, approximately 12in. by 12in. had been cut to allow hot and cold water pipe to be run into the room. The penetration had not be sealed. This room was also being used to store combustible medical supplies. The room was approximately 13ft by 7 ft. The CMS Health Surveyor confirmed the observation.



Also observed, in the same room, was an approximatley 12in. by 12in. penetration in the overhead located in the proximity of the washer and dryer. This penetration had not been sealed. The CMS Health Surveyor confirmed the observation.