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 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)
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. .