| 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) |
| 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. . |