| 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) |
| K0372 | Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 NEW Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems. 18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3 Describe any mechanical smoke control system in REMARKS. This STANDARD is not met as evidenced by: . Based on observation and interview, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 18.3.7.3, 8.5.1, and 8.5.6.2 Findings include: On 04/09/2019, during a tour of the facility from 1:00 pm to 4:15 pm, the surveyor observed the following in smoke barriers above the ceiling on the Third Floor: 1. An unsealed penetration of approximately 2 inches at the entrance to the Baby Wing 2. An unsealed penetration around the HVAC duct on Wing 3100 above the doors A member of the maintenance staff was present when this deficiency was identified. |