| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 010001 | (X3) Date Survey Completed 10/05/2017 |
| Name of Provider or Supplier Southeast Health Medical Center | Street Address, City, State 1108 Ross Clark Circle, Dothan, 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 | This STANDARD is not met as evidenced by: . K3 Building: 0105 Hospital K6 Plan Approval: 1955/ 1960/ 1965/ 1977/ 1978/ 1989/ 1997/ 2005 K7 Survey Under: 2012 Existing K8 Hospital Corridor Smoke Detection: Complete Locking Devices: Only at the two Psych Units Generators: (3) 2000 kW Diesel, installed in 2004 Type of Structure: Seven story with a basement protected noncombustible, Type II (222). This building has a complete automatic sprinkler system. During a survey conducted on this date, this building was found to be not in compliance with 42 CFR 482.41 (b) as evidenced by the following deficiencies of NFPA 101 Life Safety Code (LSC) and codes referenced by the LSC, as observed by the LSC Surveyors while accompanied by the facility maintenance personnel. . |
| K0133 | Multiple Occupancies - Construction Type CFR(s): NFPA 101 Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 This STANDARD is not met as evidenced by: . MAC Based on observation and interview, the facility failed to ensure a two hour separation was in place per requirements of: 2012 NFPA 101, 19.1.3.4, 19.1.6.1 and 8.2.1.3 Findings include: On 10/03/2017, during a tour of the facility from 8:00 am to 4:15 pm, a two hour separation was not observed between the Medical Building (Hospital) and the Women's Building A member of the maintenance staff was present when this deficiency was identified. . |
| K0161 | Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This STANDARD is not met as evidenced by: . DEVIN Based on observation and interview, the building failed to maintain the minimum fire resistive rating per the requirements of: 2012 NFPA 101, 19.1.6.1 and Table 19.1.6.1 Findings include: 1. On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, the steel structural support's protective fire proofing was observed missing from approximately 3 feet by 8 feet area located above the ceiling on the 6th floor in front of elevators O1 and O2. MAC 2. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the following was observed: a. A steel structural I-Beam was missing the two hour fire resistance rating in the utility tunnel next to MRI b. An unprotected 4x4 section of sheetrock was missing exposing a metal stud frame on the third floor in the Soiled Linen Utility Room across from room 363. c. An unprotected structural floor member (the backside of the stairwell) supporting the fourth floor was missing the two hour fire resistance rating, this was observed on the third floor south tower hallway ramp above the ceiling. d. A steel structural I-Beam was missing the two hour fire resistance rating in the Mechanical Room on the third floor interstitial space above surgery. A member of the maintenance staff was present when this deficiency was identified. . |
| K0232 | Aisle, Corridor, or Ramp Width CFR(s): NFPA 101 Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5 This STANDARD is not met as evidenced by: . Based on observation and interview, the building failed to maintain the corridors per the requirements of: 2012 NFPA 101, 19.2.3.4 (5) (a) and (c) Findings include: On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, the facility failed to maintain the Fourth Floor corridors: 1. In the 8'-0" corridors unsecured furniture was observed in the following locations: a. In the connector wing at room 470 b. At elevator B1 2. The furniture at elevator B1 was observed to be on both sides of the 8'-0" corridor. A member of the maintenance staff was present when this deficiency was identified. . |
| K0281 | Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This STANDARD is not met as evidenced by: . MAC Based on observation and interview, the building failed to ensure the illumination of means of egress per the requirements of: 2012 NFPA 101, 19.2.8 and 7.8 Findings include: On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the building failed to provide illumination of means of egress for stairwell 16. A member of the maintenance staff was present when this deficiency was identified. . |
| K0311 | Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This STANDARD is not met as evidenced by: . DEVIN Based on observation and interview, the building failed to maintain the fire resistive rating of a stairwell per the requirements of: 2012 NFPA 101, 19.3.1.1 Findings include: On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, SP/Stairwell #3 on the 6th Floor was observed with an unsealed penetration of a 4.5 inch sprinkler pipe into room 669. A member of the maintenance staff was present when this deficiency was identified. . |
| K0321 | Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This STANDARD is not met as evidenced by: . Based on observation and interview, the building failed to maintain the hazardous areas per the requirements of: 2012 NFPA 101, 19.3.2.1.3 2012 NFPA 101, 19.3.2.1.2 Findings include: 1. On 10/04/2017, during a tour of the building from 8:00 am to 5:00 pm, the Employee Shop's (TOGA's) Storage Room was observed to be over 50 sq. ft. with combustibles with the following: a. Two unsealed penetrations in the wall between the Shop and the Storage Room b. No self-closing device on the door DEVIN 2. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the following rooms located on the first floor were observed to be greater than 50 square feet with an assortment of stored combustibles and without having self-closing devices on their doors: 1. X-ray Room 1 2. X-ray Room 4 3. The room next to office 1128 in Physical Therapy A member of the maintenance staff was present when this deficiency was identified. . |
| K0325 | Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This STANDARD is not met as evidenced by: . Based on observation and interview, the building failed to maintain the Alcohol Based Hand Rub Dispensers (ABHRs) per the requirements of: 2012 NFPA 101, 19.3.2.6* (8) and (11) (f) Findings include: 1. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the Alcohol Based Hand Rub Dispensers on the First Floor in the H & V Suite/CDU were observed installed above a light switch (ignition source) at the following locations: a. Room 1133 b. Room 1134 c. Room 1138 d. Room 1142 e. Room 1147 f. At the Nurses' Station 2. On 10/04/2017, during review of documentation from 8:00 am to 5:00 pm, the building failed to provide documentation on policy and procedure on testing in accordance with the manufacturer's care and use instructions each time a new refill is installed. ROLAND 3. On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, an ABHR was observed mounted directly above a Nurses' Call Switch (ignition source) on the 7th Floor near the Nurses' Station. 36148 4. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, an Alcohol Based Hand Rub Dispenser in the GI Lab Room #1 located in the Basement was observed installed above a light switch (ignition source). A member of the maintenance staff was present when this deficiency was identified. . |
| K0351 | Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This STANDARD is not met as evidenced by: . ROLAND Based on observation and interview, the building failed to maintain the ceiling for the automatic sprinkler system per the requirements of: 2012 NFPA 101, 19.3.5.1 and 9.7.1.1 2010 NFPA 13, 8.5.4.2 2010 NFPA 13, 8.15.7.1 Findings include: On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm the following was observed: 1. A ceiling tile was found to have an approximately 2" hole in the following locations: a. Break Area b. Office Area MAC 2. The building failed to provide documentation that the canopy located next to stairwell 16 was flame retardant or provide sprinkler coverage for this canopy 3. No automatic sprinkler heads were observed in stairwell 2, that is located between the Doctor Office Building and the Medical Tower (Hospital) A member of the maintenance staff was present when this deficiency was found. . |
| 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 interview, the building failed to maintain the automatic sprinkler system riser gauges per the requirements of: 2012 NFPA 101, 19.3.5.1 2012 NFPA 101, 9.7.5 2011 NFPA 25, 5.2.4.2 Findings include: On 10/05/2017, during the review of documentation from 8:00 am to 12:15 pm, the building failed to provide documentation for the weekly inspection for the gauges on the automatic sprinklers dry system riser. A member of the maintenance staff was present when this deficiency was identified. . |
| K0355 | Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This STANDARD is not met as evidenced by: . Based on observation and interview, the building failed to maintain the fire extinguishers per the requirements of: 2012 NFPA 101, 19.3.5.12 2012 NFPA 101, 9.7.4.1 2010 NFPA 10, 6.1.3.8.1 2010 NFPA 10, 6.1.3.8.3 2010 NFPA 10, 7.2.2 2010 NFPA 10, 5.5.5.3 Findings include: 1. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the following was observed on the First Floor: a. In the Mechanical Room for Case Management a fire extinguisher was observed on the floor and it had just been inspected the day before. b. In the Insurance Suite by the water fountain a fire extinguisher was observed mounted over 5'-0" above finished floor and it had just been inspected the day before. DEVIN c. A portable fire extinguisher in the Special Procedure's Speech Therapy Office was observed obstructed by three large filing cabinets. 36148 2. On 10/04/2017, during a tour of the building from 8:00 am to 5:00 pm, the K fire extinguisher at the Service Line Grill area was observed without a placard placed near the extinguisher. A member of the maintenance staff was present when this deficiency was identified. . |
| K0372 | Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This STANDARD is not met as evidenced by: . ROLAND Based on observation and interview, the building failed to maintain the smoke barriers per requirements of: 2012 NFPA 101, 19.3.7.3 and 8.5.2.2 Findings include: On 10/04/2017, during a tour of the building from 8:00 am to 5:00 pm, the following was observed; 1. An unsealed penetration of a 2" conduit with blue and gray wires was observed in the following smoke barriers: a. Near room 570 b. Near room 585 MAC 2. An unsealed penetration was observed on the third floor in the following smoke barrier walls: a. Supply and room 357 b. Near room 356 c. In the Physician Dictation Room d. In the hallway on Peds next to men's restroom e. In Applications Analysts IT Room f. Women's Center hallway near stairwell 11 A member of the maintenance staff was present when this deficiency was identified. . |
| K0521 | HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2 This STANDARD is not met as evidenced by: . Based on observation and interview, the building failed to maintain the smoke dampers per the requirements of: 2012 NFPA 101, 19.5.2.1 2012 NFPA 101, 9.2.1 2012 NFPA 90A, 5.4.5.4 and 5.4.5.4.2 Findings include: On 10/05/2017, during a tour of the building from 8:00 am to 12:15 pm, the following smoke dampers failed to close upon activation of the fire alarm system's general alarm: 1. On the 6th Floor at room 685 2. On the 4th Floor at room 485 A member of the maintenance staff was present when this deficiency was identified. . |
| K0920 | Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This STANDARD is not met as evidenced by: . Based on observation and interview, the building failed to provide the approved UL listed 1363A or 6060-1 for patient-care-related electrical equipment (PCREE) power strips and UL standard 1363 for non-PCREE power strips per the requirements of: S&C: 14-46-LSC 2012 NFPA 99, 10.2.4 Findings include: On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the facility failed to provide approved UL listed power strips at the PACU Nurses Station. PACU Pumps were observed being plugged into the non-approved power strips. A member of the maintenance staff was present when this deficiency was identified. . |
| K0923 | Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This STANDARD is not met as evidenced by: . DEVIN Based on observation and interview, the building failed to ensure the proper separation of combustible material and stored oxygen tanks per the requirements of: 2012 NFPA 99, 11.3.2.3(2) and (11) Findings include: 1. On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, combustible materials were observed being stored within 5 feet of filled oxygen storage tank racks located in the sprinkled 4th floor Critical Care Clean Supply Room. 36148 2. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, an empty oxygen cylinder was observed unsecured in the Electrical HVAC Shop. A member of the maintenance staff was present when this deficiency was identified. . |
| K0926 | Gas Equipment - Qualifications and Training CFR(s): NFPA 101 Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99) This STANDARD is not met as evidenced by: . Based on review of documentation and interview, the building failed to ensure continuing education on the handling and risks associated with oxygen cylinders and other medical gases stored in cylinders per the requirements of: 2012 NFPA 99, 11.5.2.1 Findings include: On 10/04/2017, during the review of documentation from 8:00 am to 5:00 pm, the building failed to provide documentation on the following: 1. The qualifications and training of the building's training personnel on handling oxygen cylinders. 2. Continuing education for their personnel that handle oxygen cylinders 3. Training personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases on the risks associated with their handling and use. 4. A continuing education program for staff that handle oxygen cylinders to include periodic review of safety guidelines and usage requirements for medical gases and their cylinders. A member of the maintenance staff was present when this deficiency was identified. . |
| K0933 | Features of Fire Protection - Fire Loss Preve CFR(s): NFPA 101 Features of Fire Protection - Fire Loss Prevention in Operating Rooms Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers: * packaging is non-flammable * applicators are in unit doses * Preoperative "time-out" is conducted prior the initiation of any surgical procedure to verify: o application site is dry prior to draping and use of surgical equipment o pooling of solution has not occurred or has been corrected o solution-soaked materials have been removed from the OR prior to draping and use of surgical devices o policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99) This STANDARD is not met as evidenced by: . Based on review of documentation and interview, the building failed to provide documentation of procedures and continuing education the administration provides for "fire loss prevention in operating rooms." per the requirements of: 2012 NFPA 99, 15.13 Findings include: On 10/04/2017, during the review of documentation from 8:00 am to 5:00 pm, the building failed to provide documentation of procedures and continuing education the administration provides for "fire loss prevention in operating rooms." A member of the maintenance staff was present, when this deficiency was identified. |