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)
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. .