| 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) |
| K0342 | Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit and 200 feet travel distance is not exceeded. 20.3.4.2, 21.3.4.2, 9.6.2 This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to ensure that a manual fire alarm box was accessible, unobstructed and visible. Failure to do so could result in a delay to alert occupants of the building and fire fighters that a fire has started. This could affect employees and patients in the operating room and in the adjacent recovery room who could be under the effects of general anesthesia. Findings include: On January 31, 2019 during a walk-through of the operating room area with the CMS Health Surveyor and the facility's Operating Room Technician a manual fire alarm box was observed to be blocked by a wheeled cart upon which medical devices rested, a one foot high stool and a shelf assembly approximately six feet tall and four feet wide upon which medical equipment were stored. Both the CMS Health Surveyor and the Operating Room Technician observed that the manual fire alarm box was blocked as described. |