| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 012509 | (X3) Date Survey Completed 04/05/2023 |
| Name of Provider or Supplier North Alabama Nephrology Center | Street Address, City, State 1311 North Memorial Parkway #200, 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) |
| K0000 | . K3 Building: 0101 K6 Plan Approval: 04/04/2000 K7 Survey Under: 2012 Existing K8 ESRD Generator: One Diesel, Detroit Deisel (Model 4M4021) 325 kW (installed 2000) FACP: Mircom FX 2000 (installed 2014) Locking Devices: None Smoke Detection: Corridor How many clients daily: 40 Type of Structure: The facility is located on the second floor of a two story building; unprotected noncombustible, Type II(000). On the first floor is a different dialysis center. The facility has a complete automatic sprinkler system. During a routine recertification survey conducted on this date, the facility was found to be not in compliance with the requirements of 42 CFR, Subpart 494.60 as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyors while accompanied by the facility maintenance personnel. . |
| 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, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 21.2.1, and 7.2.2.5.3.1 This deficiency affects 1 of 3 stairwells. Findings include: On 04/04/2023, during a tour of the facility from 1:00 pm to 4:00 pm, the surveyor observed the following in the stairwell by the Water Treatment Room: 1. A shop vac, a large peice of plywood, four plastic totes, a five gallon bucket and five cardboard boxes on the landing 2. A large folding plastic table, a 48" x 18" box and some trash at the egress door A member of the maintenance staff was present when this deficiency was identified. . |
| K0345 | Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm Systems - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This STANDARD is not met as evidenced by: . Based on review of documentation, the facility failed to maintain the smoke detectors per the requirements of: 2012 NFPA 101, 21.3.4.1, and 9.6.1.3 2010 NFPA 72, 14.4.5.3.2 This deficiency affects all smoke detectors in this facility. Findings include: On 04/05/2023, during a tour of the facility from 8:30 am to 10:30 am, the facility failed to provide a smoke detector sensitivity test report completed within the past two years. There was no documentation on any previous smoke detector sensitivity test reports. A member of the maintenance staff was present when this deficiency was identified. . |
| K0351 | Sprinkler System - Installation CFR(s): NFPA 101 Sprinkler System - Installation Sprinkler systems (if installed) are installed per NFPA 13. Where more than two sprinklers are installed in a single area for protection, waterflow devices shall be provided to sound the building fire alarm system or to notify a constantly attended location such as a PBX, security office, or emergency room. 20.3.5.1, 20.3.5.2, 21.3.5.1, 21.3.5.2, 9.7.1.2, 9.7, NFPA 13 This STANDARD is not met as evidenced by: . Based on review of documentation and observation, the facility failed to provide information on the automatic sprinkler anti-freeze system per the requirements of: 2012 NFPA 101, 21.1.6.1, Table 21.1.6.1 and 9.7.1.1 2010 NFPA 13.7.6.1.5, and TIA 10-2 This deficiency affects 1 of 1 anti-freeze systems. Findings include: On 04/05/2023, during a tour of the facility from 8:30 am to 10:30 am, the facility failed to provide the following documentation on the automatic sprinkler anti-freeze system: 1. The anti-freeze placard shall provide the following information: a. Manufacture type and brand b. Concentration by volume of anti-freeze used c. Volume of anti-freeze used in system 2. The facility failed to provide certificates/letter from the manufacturer on the pre-mixed solutions installed in the anti-freeze system. The certificates/letter shall include the following information: a. Type of anti-freeze b. Concentration by volume c. The freezing point A member of the maintenance staff was present when this deficiency was identified. . |
| K0353 | Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: . Based on review of documentation and observation, the facility failed to maintain the automatic sprinkler system per the requirements of: 2012 NFPA 101, 21.1.6.1, Table 21.1.6.1, and 9.7.5 2011 NFPA 25, 5.3.4, and 5.3.1.1.1.3 This deficiency affects all sprinklers throughout the facility. Findings include: On 04/05/2023, during a tour of the facility from 8:30 am to 10:30 am, the facility failed to provide documentation on the following: 1. The annual inspection for the anti-freeze sprinkler system. The last inspection was done in 2021 per documentation from the facility 2. The 1999 fast-response sprinkler heads found throughout the facility had been replaced or a representative sample tested within 20 years of installation A member of the maintenance staff was present when this deficiency was identified. . |
| K0511 | Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2 This STANDARD is not met as evidenced by: . Based on observation, the facility failed to maintain the electrical wiring and equipment per the requirements of: 2012 NFPA 101, 21.5.1.1, and 9.1.2 2011 NFPA 70, 406.6, 404.9(A), and 314.28(C) This deficiency affects the whole facility. Findings include: On 04/04/2023, during a tour of the facility from 1:00 pm to 4:00 pm, the surveyor observed missing cover plates at the following locations: 1. An electrical outlet located behind the microwave on the back wall of the Breakroom 2. The light switch in the Roof Access Room 3. Two junction boxes, above the electrical panels in the hallway to the Water Treatment Room A member of the maintenance staff was present when this deficiency was identified. . |
| K0781 | Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies. Except, when used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 20.7.8, 21.7.8 This STANDARD is not met as evidenced by: . Based on observation, the facility failed to prohibit a portable space heating device per the requirements of: 2012 NFPA 101, 21.7.8 This deficiency affects the whole facility. Findings include: On 04/04/2023, during a tour of the facility from 1:00 pm to 4:00 pm, the surveyor observed two portable space heating devices in the following areas: 1. In the Charge Nurse's Office, between the wall and a desk. This device was on and the Charge Nurse was in her office. 2. Under the Nurses' Station desk in the treatment area. This device was not on. The facility was unable to provide documentation that the heating element did not exceed 212 degrees on either device. A member of the maintenance staff was present when this deficiency was identified. . |
| K0918 | Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This STANDARD is not met as evidenced by: . Based on observation and review of documentation, the facility failed to maintain the testing of the diesel emergency generator per the requirements of: 2012 NFPA 101, 21.2.9.1, and 7.9.2.4, 2010 NFPA 110, 8.3.7.1, 5.6.5.6, 5.6.5.6.1, 1.3, and 8.3.8 This deficiency affects the whole facility. Findings include: On 04/05/2023, during a tour of the facility from 8:30 am to 10:30 am, the facility failed to provide the following: 1. Documentation of performing monthly conductance testing on the facility's emergency generator maintenance-free batteries for the past 12 months. 2. Documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards. A member of the maintenance staff was present when this deficiency was identified. |