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 010007 (X3) Date Survey Completed 12/12/2024
Name of Provider or Supplier Mizell Memorial Hospital Street Address, City, State 702 N Main St, Opp, 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)
K0918 Electrical Systems - Essential Electric Syste
CFR(s): NFPA 101

Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)


This STANDARD is not met as evidenced by:
. Based on observation, the facility failed to maintain the Level 1 EES diesel emergency generator per the requirements of: 2012 NFPA 101, 19.2.9.1, and 7.9.2.4 2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1 2012 NFPA 99, 6.5.4.1.1.2, and 6.4.4.1.1.3 2010 NFPA 110, 8.3.7.1, 8.4.2, 8.4.2.3, 8.3.8, and 8.3.4 This deficiency affects the only Level 1 EES diesel emergency generator . Findings include: During a tour of the facility, the facility failed to provide the following for the Level 1 EES diesel emergency generator : 1. A remote manual stop station of a type to prevent inadvertent or unintentional operation 2. A label for the remote manual stop station 3. The facility failed to provide the following documentation on the Level 1 EES diesel emergency generator: a. Performing monthly testing on the battery for the past 12 months b. The monthly 30 minute exercise failed to meet the requirements per 8.4.2 and the facility failed to provide documentation on an annual supplemental 1.5-hour load test per 8.4.2.3 c. Annual fuel quality test approved by ASTM standards A member of the maintenance staff was present when this deficiency was identified. .