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)
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. .