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)
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. .