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 010006 (X3) Date Survey Completed 07/15/2010
Name of Provider or Supplier North Alabama Medical Center Street Address, City, State 1701 Veterans Drive, Florence, 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)
K0069 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

Cooking facilities are protected in accordance with 9.2.3. 19.3.2.6, NFPA 96


This STANDARD is not met as evidenced by:
The facility failed to maintain the dietary hood. Findings include: A) During the survey, the filters in the dietary hood in the Short Line Grill, were observed to be damaged, causing the filters not to be held tight and firmly in place. NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place. B) During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank. For the Main Kitchen, and the Short Line Grill, which is two separate extinguishing sytems. NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) The system shows no physical damage or condition that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blow-off caps, where provided, are intact and undamaged. (h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.