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 04/11/2019
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)
K0353 Sprinkler System - Maintenance and Testing
CFR(s): NFPA 101

Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25


This STANDARD is not met as evidenced by:
. Based on review of documentation and interview, the facility failed to provide documentation on the testing and inspection of the automatic sprinkler system per requirements of: 2012 NFPA 101, 4.6.12.3, 4.6.12.4, 9.7.5, and 9.7.7 2011 NFPA 25, Table 5.1.1.2, 5.2.4.1, 5.3.4, and TIAs 11-1, 11-2, 11-3 and 11-4 This deficiency could affect all occupants. On 04/11/2019, during a tour of the facility from 8:00 am to 12:30 pm, the facility failed to provide the following documentation : 1. The monthly inspections on the wet sprinkler riser gauges 2. The quarterly automatic sprinkler inspection records for the past 12 months. Only one report dated 02/20/2019 was provided for review. The service tags on the riser indicated 08/2018, 08/17, 09/16, 02/16 as dates the system was inspected. A member of the maintenance staff was present when the deficiency was found. .