2023 VA West Roxbury Annual Inspection_Redacted.pdf

2023 Medical Gas Testing and Evaluation

Testing Completed July 20th and 21st, 2023

August 1, 2023

VA Boston Healthcare Systems 1400 VFW Parkway

West Roxbury, MA 02132

TABLE OF CONTENTS BY SECTION

Table of Contents Section Introduction

Purpose of Inspection and Evaluation ............................................................... 1.1

Methodology to Complete Inspection .............................................................. 1.2

Signature Page .................................................................................................. 1.3

Inventory of Medical Gas Components

Summary Maintenance Deficiencies

Summary Compliance Deficiencies

Summary General Comments

Newer Health Care Facility Code Recommendations

Master Alarm Testing Results

Oxygen Particulate Testing Results

Leak Testing of Columns and Booms

Medical Air Moisture Testing Results

Alarm Testing Results

Zone Valve Testing Results

Outlet/Inlet Testing Results

Source Testing Results

Verification Reports Completed

Repairs Completed

Credentials

PURPOSE OF INSPECTION AND EVALUATION

The following inspection report is designed using the NFPA 99, 2012 edition code, which is the current Center for Medicare & Medicaid Services standard.

The purpose of an inspection and evaluation of a medical gas system is to determine if the system functions as designed, to suggest areas for improvement, and to note what could be upgraded to meet current NFPA 99 criteria so that patient/employee safety is always being maximized.

Your facility was inspected by representatives using all state-of-the-art testing equipment carrying all credentials necessary to properly inspect medical gas systems.

It is important to understand that the findings in this report may or may not be looked at as a patient or employee safety issue, but each item needs to be evaluated by hospital risk management personnel to determine if there are safety issues.

NFPA 99, 2012 EDITION PARAGRAPH 5.1.1.4 STATES THAT AN EXISTING SYSTEM

THAT IS NOT IN STRICT COMPLIANCE WITH THE PROVISIONS OF THIS CODE

SHALL BE PERMITTED TO BE CONTINUED IN USE AS LONG AS THE AUTHORITY

HAVING JURISDICTION HAS DETERMINED THAT SUCH USE DOES NOT

CONSTITUTE A DISTINCT HAZARD TO LIFE.

This report also may satisfy any preventative maintenance requirement from all regulatory agencies. Please note that our methodology constantly changes to meet any changes in NFPA and other regulatory requirements.

THIS REPORT REFLECTS THE DEFICIENCIES THAT WERE OBSERVED AT THE TIME

OF THE INSPECTION. OTHER DEFICIENCIES MAY ALSO EXIST THAT WERE NOT

OBSERVED DURING THIS INSPECTION.

METHODOLOGY TO COMPLETE INSPECTION

Medical Gas Sources – Medical air compressor, vacuum pumps, gas manifolds, and any other device used to deliver medical gases to patients.

1. Inventoried by location.

2. Leak checked and documented.

3. Recommendations to comply with NFPA 99, 2012 edition Health Care Facilities Code.

Master Alarm Panels – Alarm panels located at two separate locations throughout the facility. These panels monitor conditions directly from the medical gas sources.

2. Tested by removing existing pressure switches and other sensing devices to test the actuation points. No interruption of service is necessary if each device is mounted on code compliant demand fittings.

3. Verify proper points are being monitored at each panel.

4. Verify each panel is in the proper locations.

5. Verify proper labeling.

Area Alarm Panels – Alarm panels that are located throughout the facility that monitor medical gas pressures for the area only.

2. Tested by lowering pressure in each zone for each gas and documenting the alarm point.

3. Verify proper location.

4. Verify proper labeling.

Zone Valve Boxes – Accessible valves typically found in a corridor covered by a plastic window used mostly for emergency purposes.

2. Checked for leakage from packing, flange, and gauge port using oxygen safe leak detector.

3. Verify proper labeling.

4. Verify proper locations.

Medical Gas Outlets/Inlets – Connection points for each gas located mostly in patient areas. (Any outlets/inlets located in Airborne or Droplet precaution rooms will not be tested.)

1. Inventoried by location in each room or area inspected left to right and then top to bottom.

2. Complete an operational pressure test on each outlet and document pass/fail. (Test Parameters per NFPA 99, 2012 edition)

3. Check function of outlet/inlet and latching mechanism.

4. Check for leakage with equipment and without equipment attached.

5. Document connection type and outlet/inlet manufacturer.

Oxygen Particulate Analysis – Particulate is often found in existing medical gas systems due to improper installation methods that were used in the past.

1. Samples are taken on each floor in each building. (See particulate analysis section)

Medical Air Dewpoint Analysis – Moisture is removed from medical air systems at the source. Periodic Analysis of moisture throughout the facility is important to prevent contamination.

1. Samples are taken on each floor in each building. (See Medical Air Dewpoint Analysis Section)

2. A sample will be taken at the medical air source to compare building samples to.

Emergency Oxygen Supply Connection Box – This box is typically mounted on the outside of a facility to facilitate the back feeding of the oxygen system if there is an interruption in service.

2. Check existing location for proper compliance.

3. Check existing piping arrangement to insure proper order of components.

4. Check to make sure box is secured.

Testing to ensure all medical gas booms, and columns are leak free – Most operating rooms and procedure rooms have some sort of device to help clinical personnel use the medical gases in the middle of the room by the patient. These devices are either medical gas booms or columns. The hoses and threaded connections inside these devices need to be checked periodically to ensure that there are no leaks.

1. All hoses and secondary equipment were removed from the outlets on each boom and column.

2. A test pressure for each system was observed and documented.

3. All medical gas valves were shut over a period of 10-minutes.

4. After the test period of 10-minutes had past the pressure was observed once again.

5. Any pressure drop was recorded.

6. Recommendations will be made to find existing leaks and to make repairs.

Reporting

1. All data was collected and broken down into (3) categories:

a. Items that are maintenance issues and need repair, adjustment, calibration, relabeling, or replacement. These items may or may not be an immediate patient safety issue but can be taken care of easily and without much coordination.

b. Design issues that do not meet NFPA 99, 2012 edition Health Care Facilities Code and need to be updated in the future. These items may or may not be patient safety issues but need to be addressed by hospital risk management personnel as soon as possible.

c. General comments that don’t fit in either category A and/or B.

Department Floor Area

Alarm Zone

Valves Outlet/ Inlets

Outlet/Inlets Tested

Miscellaneous Data

Pulmonary G 0 3 16 15 Clinical

Engineering G 0 0 15 11

MRI G 1 3 12 12

CT Scan G 0 3 9 9

Speech Pathology 1 0 1 0 0

EEG 1 0 1 8 8

Cardiology 1 0 0 18 18 Radiology 1 1 3 18 18 Endoscopy 1 1 3 20 20

2 South 2 3 9 69 63 2 North 2 7 18 78 76 3 North 3 1 3 84 75

PACU 3 1 3 64 64

PCU 3 1 3 96 91

4 North 4 1 3 93 73 Environmental Management 4 0 2 6 0

MICU 4 1 3 0 0

CCU 5 1 3 56 53

Offices 5 0 3 9 9 Catheterization

Lab 5 4 3 23 23

Total Count: 23 70 694 638 91% Tested

INVENTORY OF MEDICAL GAS COMPONENTS

VA West Roxbury - Building 1

Alarm Zone

Valves Outlet/ Inlets

Outlet/Inlets Tested

Miscellaneous Data

A-G Ward G 1 6 90 85 Angiography Suite 1 2 9 12 9

A-1 Ward 1 1 6 90 88 A-2 Ward 2 1 3 129 124 SCI Clinic 2 1 3 9 9

Surgical Services 3 3 27 98 94

SICU 3 2 6 56 45

Total Count: 11 60 484 454 93% Tested

VA West Roxbury - Building 2

Alarm Zone

Valves Outlet/ Inlets

Outlet/Inlets Tested

Miscellaneous Data

Vascular Lab G 0 3 3 3 Emergency Department

G 1 3 80 80

X-Ray/Specialty Clinic

G 0 3 12 9

Personnel Security G 0 3 3 3

Nuclear Medicine 2 1 9 16 16

Total Count: 2 21 114 111 97% Tested

VA West Roxbury - Building 3

Alarm Zone

Valves Outlet/ Inlets

Outlet/Inlets Tested

Miscellaneous Data

Building 1 23 70 694 638

Building 2 11 60 484 454

Building 3 2 21 114 111

Total Count: 36 151 1292 1203 93% Tested

VA West Roxbury - Total Inventories

SUMMARY OF MAINTENANCE DEFICIENCIES

Building 1

Speech Pathology

1. Oxygen zone valve located left of Room 1D129 leaks at the stem.

EEG

1. Oxygen zone valve located left of Room 1D138 leaks at the stem.

2 North

1. Area alarm panel located left of 2D112 has a defective oxygen and medical air display.

2. Area alarm panel located left of 2D124B has a defective medical air display.

3 North

1. Room 3D112 – 2nd Vacuum inlet leaks.

4 North

1. Room 4D113:

a. 1st Oxygen outlet leaks.

b. 1st Vacuum inlet has a low flow of 2.75 scfm.

CCU

1. Oxygen zone valve located left of 5C113 leaks at the stem in the open position.

2. Bed 7 – 2nd vacuum inlet leaks.

Building 2

AG Ward

1. Oxygen zone valve located left of Room AG32 has a leak at the stem in the off position.

2. Room AG-34 – 1st Oxygen outlet leaks.

A2 Ward

1. Oxygen zone valve located right of Room A-231 leaks at the stem in the on position.

2. Medical air zone valve located right of Room A-231 leaks at the stem in the off

3. Room A-219 – 2nd Vacuum inlet leaks.

Surgical Services

1. Operating Room 1 – 1st Vacuum inlet on ceiling 3 leaks at the end of the hose.

2. Operating Room 2:

a. 1st vacuum inlet on ceiling has a low flow of 1.75 scfm at the end of the hose.

b. 2nd vacuum inlet on the ceiling leaks at the end of the hose.

3. Operating Room 3:

a. Oxygen zone valve located left of OR 3 leaks at the stem in the off position.

b. Medical air zone valve located left of OR 3 leaks at the stem in the off

4. Operating Room 4 – Oxygen zone valve located left of OR 4 leaks at the stem in the off position.

5. Operating Room 6:

a. The ten-minute standing pressure test for vacuum lost 23” Hg.

b. 2nd vacuum inlet on boom 2 leaks.

Building 3

Emergency Department

1. Area alarm panel located at the Nurses’ Station has a defective vacuum display.

Sources

Bulk Oxygen System (In-House Components)

1. Threaded check valve located on the oxygen main line piping in Building 2 leaks.

2. Threaded check valve located on the EOSC piping in Building 2 leaks.

EOSC (Building 1)

1. Pressure relief vent line located to the right of Building 2 loading dock is severely damaged.

SUMMARY OF COMPLIANCE DEFICIENCIES

Building 1

Pulmonary

1. The outlets/inlets in Rooms GB118D and GB118E are not supplied through a zone valve. 1

Clinical Engineering

1. The outlets/inlets in Clinical Engineering are not supplied through a zone valve. 2

MRI

1. Area alarm panel located right of Room GB156 is a non-compliant panel which does not have separate visual indicators for each condition monitored. 3

2. Zone valves located right of Room GB156 are installed in a room with the station outlets/inlets that they control. 4

Speech Pathology

1. Oxygen zone valve located left of Room 1D129 is installed in the same zone valve box assembly with flammable gases. 5

EEG

1. Oxygen zone valve located left of Room 1D138 is installed in the same zone valve box assembly with flammable gases. 6

2. Vacuum inlets in this department are not supplied through a zone valve. 7

Cardiology

1. Vacuum inlets in this department are not supplied through a zone valve. 8

2 North

1. Area alarm located left of 2D104 needs to be labeled for the area it monitors.9

3 North

1. Zone valves located right of Room 3D112 have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 10

PACU

1. Area alarm panel located left of Room 3B108 is a non-compliant panel which does not have separate visual indicators for each condition monitored. 11

2. Area alarm panel located left of Room 3B108 needs to be labeled for the area it monitors.12

4 North

1. Area alarm panel located right of Room 4D113 needs to have “Doctor’s Office” added to the labeling.13

2. Zone valves located right of Room 4D113:

a. Shut off the supply to the Environmental Management zone valves located left of Room 4D126A. 14

b. Have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 15

Environmental Services

1. Zone valves located left of Room 4D126A are redundant and are shut off by the zone valves located right of 4D113. 16

CCU

1. Zone valves located left of Room 5C113:

a. Are installed in a room with the station outlets/inlets that they control. 17

b. Have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 18

Offices

1. Zone valves located left of Room 5B112 have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 19

Cath Lab

1. Area alarm panel located inside Room 5D106 is a non-compliant panel which does not have separate visual indicators for each condition monitored. 20

2. Zone valves located left of 5D103 have no pressure/vacuum indicators on the station outlet/inside of the zone valves. 21

Building 2

A-G Ward

1. Zone valves located right of Room AG38 have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 22

2. Zone valves located left of Room AG32 have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 23

A-1 Ward

1. Zone valves located right of Room A125 have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 24

2. Zone valves located left of Room A119 Storage have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 25

A-2 Ward

1. Zone valves located right of Room A231 have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 26

Surgical Services

1. Zone valves controlling Operating Rooms 1-4 have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. 27

2. There are no dedicated WAGD inlets installed in anesthetizing locations Operating

Rooms 1-5. 28

Building 3

Emergency Department

1. Area alarm panel located at the Nurses’ Station is a non-compliant panel which does not have separate visual indicators for each condition monitored. 29

2. Vacuum zone valve located left of GA100 has no pressure/vacuum indicator on the station outlet/inlet side of the zone valve.30

Personnel Security

1. Zone valves located inside Room GB105A are installed in a room with the station outlets/inlets that they control. 31

Nuclear Medicine

1. Zone valves located on the Ground Floor in the Loading Dock hallway shut off the medical gas supply to the 2nd Floor Nuclear Medicine zone valves which are on different floor of the Hospital. 32

2. All zone valves located on the 2nd floor of the Nuclear Medicine Department are redundant and shut off by the zone valves on the Ground Floor. 33

Bulk Oxygen System

1. The outdoor bulk cryogenic liquid system needs to be provided with a minimum of two entry/exits. 34

2. Does not have permanent guard posts installed around the bulk pad site. 35

3. Main line piping is unprotected where it enters the ground on the bulk pad. 36

Bulk Oxygen System (In-House Components)

1. Oxygen check valves located on the main line and EOSC piping in Building 2 have threaded connections. 37

2. Parts of the oxygen main line piping are painted. 38

Vacuum Pump (Bld. 1)

1. All turns, offsets, and other changes in direction to the main line piping are not completed using acceptable joining methods. 39

Medical Air Compressor (Bld. 1)

1. Medical air intake is not located a minimum of 25 feet from ventilating system exhausts, fuel storage vents, combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other noxious fumes. 40

2. Piping has a valve with no brazed cap or tubing allowances for cutting and re-brazing. 41

Medical Air Compressor (Bld. 2)

1. All turns, offsets, and other changes in direction to the medical air intake piping are not completed using acceptable joining methods. 42

2. Medical air intake is not located a minimum of 25 feet from ventilating system exhausts, fuel storage vents, combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other noxious fumes. 43

Vacuum Pump (Bld. 2)

1. Service valves on the exhaust piping do not permit in-line serviceability. 44

2. All turns, offsets, and other changes in direction to the vacuum piping are not completed using acceptable joining methods. 45

Medical Air Compressor (Bld. 3)

1. All turns, offsets, and other changes in direction to the medical air intake piping are not completed using acceptable joining methods. 46

Vacuum Pump (Bld. 3)

1. All turns, offsets, and other changes in direction to the main line and exhaust piping are not completed using acceptable joining methods. 47

2. Parts of exhaust piping for the vacuum system are not installed with compliant tubing. 48

1 NFPA 99, 2012 edition paragraph 5.1.4.8

2 NFPA 99, 2012 edition paragraph 5.1.4.8

3 NFPA 99, 2012 edition paragraph 5.1.9.1 (1)

4 NFPA 99, 2012 edition paragraph 5.1.4.8 (1)

5 NFPA 99, 2012 edition paragraph 5.1.4.2.3

6 NFPA 99, 2012 edition paragraph 5.1.4.2.3

7 NFPA 99, 2012 edition paragraph 5.1.4.8

8 NFPA 99, 2012 edition paragraph 5.1.4.8

9 NFPA 99, 2012 edition paragraph 5.1.9.1 (7)

10 NFPA 99, 2012 edition paragraph 5.1.4.8.3

11 NFPA 99, 2012 edition paragraph 5.1.9.1 (1)

12 NFPA 99, 2012 edition paragraph 5.1.9.1 (7)

13 NFPA 99, 2012 edition paragraph 5.1.9.1 (7)

14 NFPA 99, 2012 edition paragraph 5.1.4.8.2

15 NFPA 99, 2012 edition paragraph 5.1.4.8.3

16 NFPA 99, 2012 edition paragraph 5.1.4.8.2

17 NFPA 99, 2012 edition paragraph 5.1.4.8 (1)

18 NFPA 99, 2012 edition paragraph 5.1.4.8.3

19 NFPA 99, 2012 edition paragraph 5.1.4.8.3

20 NFPA 99, 2012 edition paragraph 5.1.9.1 (1)

21 NFPA 99, 2012 edition paragraph 5.1.4.8.3

22 NFPA 99, 2012 edition paragraph 5.1.4.8.3

23 NFPA 99, 2012 edition paragraph 5.1.4.8.3

24 NFPA 99, 2012 edition paragraph 5.1.4.8.3

25 NFPA 99, 2012 edition paragraph 5.1.4.8.3

26 NFPA 99, 2012 edition paragraph 5.1.4.8.3

27 NFPA 99, 2012 edition paragraph 5.1.4.8.3

28 NFPA 99, 2012 edition paragraph 5.1.5.16

29 NFPA 99, 2012 edition paragraph 5.1.9.1 (1)

30 NFPA 99, 2012 edition paragraph 5.1.4.8.3

31 NFPA 99, 2012 edition paragraph 5.1.4.8 (1)

32 NFPA 99, 2012 edition paragraph 5.1.4.8 (2)

33 NFPA 99, 2012 edition paragraph 5.1.4.8 (2)

34 NFPA 99, 2012 edition paragraph 5.1.3.3.2 (3), NFPA 55, 2020 edition chapters 8 & 9 and CGA M-1 paragraph 8.3

35 NFPA 55, 2016 edition paragraph 4.11.1

36 NFPA 99, 2012 edition paragraph 5.1.10.11.2

37 NFPA 99, 2012 edition paragraph 5.1.4.11 (4)

38 NFPA 99, 2012 edition paragraph 5.1.11.1.3

39 NFPA 99, 2012 edition paragraph 5.1.10.3.1

40 NFPA 99, 2012 edition paragraph 5.1.3.6.3.12 (B)

41 NFPA 99, 2012 edition paragraph 5.1.4.10.2

42 NFPA 99, 2012 edition paragraph 5.1.10.3.1

43 NFPA 99, 2012 edition paragraph 5.1.3.6.3.12 (B)

44 NFPA 99, 2012 edition paragraph 5.1.4.8.6

45 NFPA 99, 2012 edition paragraph 5.1.10.3.1

46 NFPA 99, 2012 edition paragraph 5.1.10.3.1

47 NFPA 99, 2012 edition paragraph 5.1.10.3.1

48 NFPA 99, 2012 edition paragraph 5.1.10.2.1

SUMMARY OF GENERAL COMMENTS

1. If patients are being subjected to moderate sedation, deep sedation, or general anesthesia in the following rooms, then there are specific requirements per NFPA 99 that need to be adhered to for this location. The facility shall determine what level of sedation/analgesia that is being administered and make the appropriate changes.

a. CT Scan

b. MRI

c. Catheterization labs

2. The following were not located for compliance inspection in 2023:

a. Building 3 medical air intake.

b. Building 3 vacuum pump exhaust.

3. The bulk oxygen signals were not tested during the annual medical gas inspection and evaluation. These signals are tested by your bulk oxygen supplier and should be reported with their annual preventative maintenance program. These signals include the following:

a. Oxygen Main Liquid Level Low

b. Oxygen Reserve in Use

c. Oxygen Reserve Liquid Level Low

d. Oxygen Reserve Low Pressure

4. The location of the emergency oxygen supply connection was inspected for compliance per NFPA 99. The future use of a temporary oxygen source will be inspected during a verification process, and the location of that oxygen source may not meet the requirements of NFPA 99 and/or NFPA 55.

NEWER CODE RECOMMENDATIONS FOR HEALTHCARE FACILITIES

Effective July 5, 2016, Center for Medicare & Medicaid Services adopted NFPA 99, 2012 edition of the Health Care Facilities Code. The following chart shows the different changes that may affect your facility.

Any items listed below that are included in these future editions may become applicable upon when CMS and/or the state adopts newer editions of the NFPA 99 Health Care Facilities Code.

Item Description NFPA 99, 2015 edition

NFPA 99,

2018 edition

NFPA 99,

2021 edition

The outdoor central supply system, since it is greater than 18.6 m2 (200 ft2), needs to be provided with a minimum of two entry/exits.

5.1.3.3.2 (4)

The cryogenic fluid central supply system does not have an auxiliary source connection installed on the patient side of the source valve.

5.1.3.5.7 5.1.3.5.7 5.1.4.10

The auxiliary source connection valve does not have a removable plug or cap installed.

5.1.3.5.7.1 5.1.3.5.7.1 5.1.4.10.1

The auxiliary source connection valve is not secured in its normally closed position.

5.1.3.5.7.2 5.1.3.5.7.2 5.1.4.10.2

Vacuum exhaust is located less than 25 feet from any door, window, air intake, or other openings in buildings or places of public assembly.

5.1.3.7.6.2 (2) 5.1.3.7.7.2 (2) 5.1.3.7.7.2 (2)

WAGD exhaust is located less than 25 feet from any door, window, air intake, or other openings in buildings or places of public assembly.

5.1.3.8.5 and

5.1.3.7.6.2 (2)

5.1.3.8.5 and

5.1.3.7.7.2 (2)

5.1.3.8.5 and

5.1.3.7.7.2 (2)

There are no alarms installed at the master alarms allowing the temporary oxygen supply to be monitored while in use.

5.1.3.5.13.2 (8)

Medical air intake shall be labeled in accordance with 5.1.11.1 with any method that would distinguish it as a medical air intake.

5.1.3.6.3.11 (I)

Vacuum exhaust shall be labeled in accordance with 5.1.11.1 with any method that would distinguish it as a vacuum exhaust.

5.1.3.7.7.4

WAGD exhaust shall be labeled in accordance with 5.1.11.1 with any method that would distinguish it as a WAGD exhaust.

5.1.3.8.5 and 5.1.3.7.7.4

Specific source, service, and zone valves do not have threaded purge ports on the patient side and source side.

5.1.4.1.6 (8)

Since certain rooms have the station outlets/inlets installed in a down-facing position, the outlets/inlets need to be DISS connectors.

5.1.5.17 5.1.5.17

Specific zone valves throughout the facility need to be relabeled so that the label is not affixed to the removable cover and is visible from outside the zone valve box assembly.

5.1.11.2.7 5.1.11.2.7 5.1.11.2.8

The sleep lab outlets downstream of the flow control device needs to be labeled to include a warning not to use the outlet for ventilating patients.

5.1.11.3.1.1 5.1.11.3.1.1 5.1.11.3.1.1

Source equipment needs to be labeled with the emergency contact information for the department or individual responsible for maintaining the equipment.

5.1.11.5 (4) 5.1.11.5.1

Where vacuum systems are used to serve WAGD systems in accordance with 5.1.10.2.3.1, labeling for the medical surgical vacuum source shall indicate that it serves both systems.

5.1.11.5.2

When clinical spaces are converted to nonclinical spaces, medical gas inlets and outlets that are not accessible for maintenance and testing shall be either removed or decommissioned.

5.1.14.3.5

Alarm Testing

Floor Monitors Department Location Labeled Pass/Fail Comment G All Sources (Master) Switchboard Switchboard Office Yes Pass G All Sources (Master) Facilities Boiler Plant Yes Pass

G MRI MRI R/O GB-156 Yes Pass No separate visual indicators 1 1B108, 109, 113, 117, 142, 146 Radiology Across from 1B-108 Yes Pass 1 1B148, 155, 156, 157, 160 Endoscopy 1B151 Yes Pass 2 2B104, 2B105, 2B140-2B142 2 South At central nurses station Yes Pass 2 2B108-2B109, 2B111-2B112 2 South Across from central nurse station Yes Pass 2 2B129-2B131, 2B133-2B136 2 South At central nurses station Yes Pass 2 2 North Zones 1-6 2 North At central nurses station Yes Pass Rings for all 6 zones 2 2D103-2D104 2 North L/O 2D104 Yes Pass Zone 5, needs to be labeled for area 2 2D107-2D110 2 North R/O 2D109 Yes Pass Zone 2

2 2D111-2D114 2 North L/O 2D112 Yes Pass Zone 1, Defective oxygen and medical air digital display

2 2D118-2D120 2 North Across from 2D124B Yes Pass Zone 3 2 2D124-2D125 2 North L/O 2D124B Yes Pass Zone 4, Defective medical air digital display 2 2D128-2D129 2 North R/O 2D128 Yes Pass Zone 6 3 3 North 3 North R/O 3D112 Yes Pass

3 PACU PACU L/O 3B108 Yes Pass No separate visual indicators, needs to be labeled for area it covers

3 PCU PCU At nurses station Yes Pass

4D103-105, 109-113, 115-120, 140-141, Doctors Office 4 North R/O 4D113 Yes Pass Need to add Doctor's Office to label 4 MICU Beds 1-8 MICU At nurses station Yes N/A *Area is under construction 5 CCU Beds 1-8 CCU R/O 5C115 Yes Pass 5 Cath Labs Cath Lab Inside 5D109 Yes Pass All alarms ring when testing 5 Cath Labs Cath Lab Inside 5D104 Yes Pass All alarms ring when testing 5 Cath Labs Cath Lab L/O 5D103 Yes Pass All alarms ring when testing

5 Cath Labs Cath Lab Inside 5D106 Yes Pass All alarms ring when testing, No separate visual indicators

Alarm Testing

Floor Monitors Department Location Labeled Pass/Fail Comment

Master Alarm Testing Results

Source Line Pressure High Pressure Low Pressure

Bldg. 1 Oxygen Bldg 1 52 psig 62 psig 44 psig Under the Pool Bldg. 2 Oxygen Bldg 2 50 psig 62 psig 48 psig Bldg. 1 Medical Air Bldg 1 51 psig 60 psig 38 psig DP -33.1 Bldg. 2 Medical Air Bldg 2 53 psig 60 psig 40 psig DP -12.3 Bldg. 3 Medical Air Bldg 3 52 psig 60 psig 39 psig DP -21.2 Bldg. 1 Vacuum Pump Bldg 1 -22"Hg - -12"Hg Bldg. 2 Vacuum Pump Bldg 2 -21"Hg - -12"Hg Bldg. 3 Vacuum Pump Bldg 3 -20"Hg - -11"Hg

Area Alarm Testing

Floor Monitors Department Location Labeled Pass/Fail Comment

G

AG26, 31, 34-36, 38-43, 45,

51, 59 A-G Ward Nurse's Station Yes Yes 1 A-106 Procedure Room 1 Angiography Suite Left of A-106 Procedure Yes Yes 1 A-106C Angiography Suite Inside Control Room Yes Yes * Area is under construction

A113, 116, 120, 123-132, 138 A-1 Ward Right of A-122B Yes Yes

A218, 219, 225, 226, 229-

236, 238, 239, 244 A-2 Ward Nurse's Station Yes Yes 2 2B117, 118, 120 SCI Clinic Nurse's Station Yes Yes 3 Main line OR's Surgical Services Inside A-306 Yes Yes Nitrous not in service 3 OR 5 Surgical Services Right of OR 5 Yes Yes 3 Main line Surgical Services Right of OR 6 Yes Yes 3 Beds 1-6 SICU Across from Bed 3 Yes Yes 3 Beds 7-8 SICU Left of Bed 7 Yes Yes

Area Alarm Testing

Floor Monitors Department Location Labeled Pass/Fail Comment G ED 1-7, 11-13 Emergency Department Nurse's station Yes Fail Vacuum display defective, No separate visual indicators G GB105A Personnel Security Inside GB105A Yes N/A Not in Service

2C111, 113, 115, 118, 128 Nuclear Medicine Reception Desk Yes Pass

Zone Valve Testing

Floor Department Controls Gases Location Labeled Ports Notes G Pulmonary GB140, 141A, 144, 146 Oxygen Across from GB137 Yes No G Pulmonary GB140, 141A, 144, 146 Medical Air Across from GB137 Yes No G Pulmonary GB140, 141A, 144, 146 Vacuum Across from GB137 Yes No G MRI MRI Oxygen Right of GB156 Yes No In same room as outlets/inlets controlled G MRI MRI Medical Air Right of GB156 Yes No In same room as outlets/inlets controlled G MRI MRI Vacuum Right of GB156 Yes No In same room as outlets/inlets controlled G CT Scan GB102, 103, 105 Oxygen Right of GB103 Yes No Anesthetizing location (Gen. comments) G CT Scan GB102, 103, 105 Medical Air Right of GB103 Yes No Anesthetizing location (Gen. comments) G CT Scan GB102, 103, 105 Vacuum Right of GB103 Yes No Anesthetizing location (Gen. comments) 1 Speech Pathology 1D129 Oxygen Left of 1D129 Yes No Leaks at stem, In box with non-medical gas

1 EEG 1D135, 136, 138 Oxygen Left of 1D138 Yes No No vacuum zone valve, Leaks at stem, In box with non-medical gas

1 Radiology 1B108, 109, 113, 117, 142, 146 Oxygen Across from 1B108 Yes No 1 Radiology 1B108, 109, 113, 117, 142, 146 Medical Air Across from 1B108 Yes No 1 Radiology 1B108, 109, 113, 117, 142, 146 Vacuum Across from 1B108 Yes No 1 Endoscopy 1B148, 155, 156, 157, 160 Oxygen Left of 1B148 Yes No 1 Endoscopy 1B148, 155, 156, 157, 160 Medical Air Left of 1B148 Yes No 1 Endoscopy 1B148, 155, 156, 157, 160 Vacuum Left of 1B148 Yes No 2 2 South 2B104, 2B105, 2B140-2B142 Oxygen Left of 2B105 Yes No 2 2 South 2B104, 2B105, 2B140-2B142 Medical Air Left of 2B105 Yes No 2 2 South 2B104, 2B105, 2B140-2B142 Vacuum Left of 2B105 Yes No

2 2 South 2B108-2B109, 2B111-2B112 Medical Air Across from central nurses station Yes No

2 2 South 2B108-2B109, 2B111-2B112 Oxygen Across from central nurses station Yes No

2 2 South 2B108-2B109, 2B111-2B112 Vacuum Across from central nurses station Yes No 2 2 South 2B129-2B131, 2B133-2B136 Oxygen Left of 2B129 Yes No 2 2 South 2B129-2B131, 2B133-2B136 Medical Air Left of 2B129 Yes No 2 2 South 2B129-2B131, 2B133-2B136 Vacuum Left of 2B129 Yes No 2 2 North 2D103-2D104 Oxygen Left of 2D104 Yes No 2 2 North 2D103-2D104 Medical Air Left of 2D104 Yes No 2 2 North 2D103-2D104 Vacuum Left of 2D104 Yes No 2 2 North 2D107-2D110 Oxygen Right of 2D109 Yes No 2 2 North 2D107-2D110 Medical Air Right of 2D109 Yes No 2 2 North 2D107-2D110 Vacuum Right of 2D109 Yes No 2 2 North 2D111-2D114 Oxygen Left of 2D112 Yes No

Floor Department Controls Gases Location Labeled Ports Notes 2 2 North 2D111-2D114 Medical Air Left of 2D112 Yes No 2 2 North 2D111-2D114 Vacuum Left of 2D112 Yes No 2 2 North 2D118-2D120 Oxygen Across from 2D124B Yes No 2 2 North 2D118-2D120 Medical Air Across from 2D124B Yes No 2 2 North 2D118-2D120 Vacuum Across from 2D124B Yes No 2 2 North 2D124-2D125 Oxygen Left of 2D124B Yes No 2 2 North 2D124-2D125 Medical Air Left of 2D124B Yes No 2 2 North 2D124-2D125 Vacuum Left of 2D124B Yes No 2 2 North 2D128-2D129 Oxygen Right of 2D128 Yes No 2 2 North 2D128-2D129 Medical Air Right of 2D128 Yes No 2 2 North 2D128-2D129 Vacuum Right of 2D128 Yes No 3 3 North 3 North Oxygen Right of 3D112 Yes No No gauges 3 3 North 3 North Medical Air Right of 3D112 Yes No No gauges 3 3 North 3 North Vacuum Right of 3D112 Yes No No gauges 3 PACU PACU Oxygen Right of PACU Yes No 3 PACU PACU Medical Air Right of PACU Yes No 3 PACU PACU Vacuum Right of PACU Yes No 3 PCU PCU Oxygen Left of PCU entrance Yes No 3 PCU PCU Medical Air Left of PCU entrance Yes No 3 PCU PCU Vacuum Left of PCU entrance Yes No

4 4 North

4D103-105, 109-113, 115-120, 126, 126A, 140-141, Doctors

Office Oxygen Right of 4D113 Yes No Shuts off supply to Environmental Management, No gauges, need to add Doctor's Office to label

4 4 North

4D103-105, 109-113, 115-120, 126, 126A, 140-141, Doctors

Office Medical Air Right of 4D113 Yes No Shuts off supply to Environmental Management, No gauges, need to add Doctor's Office to label

4 4 North

4D103-105, 109-113, 115-120, 126, 126A, 140-141, Doctors

Office Vacuum Right of 4D113 Yes No Shuts off supply to Environmental Management, No gauges, need to add Doctor's Office to label

Environmental Management 4D-126, 126A Oxygen Left of 4D-126A Yes No Redundant

Environmental Management 4D-126, 126A Vacuum Left of 4D-126A Yes No Redundant

4 MICU Beds 1-8 Medical Air Nurses' Station Yes No * Area is under construction 4 MICU Beds 1-8 Oxygen Nurses' Station Yes No * Area is under construction 4 MICU Beds 1-8 Vacuum Nurses' Station Yes No * Area is under construction 5 CCU Beds 1-8 Vacuum Left of 5C113 Yes No In same room as outlets, No gauges

Floor Department Controls Gases Location Labeled Ports Notes

5 CCU Beds 1-8 Oxygen Left of 5C113 Yes No In same room as outlets, No gauges, leaks in the open position at the stem

5 CCU Beds 1-8 Medical Air Left of 5C113 Yes No In same room as outlets, No gauges 5 Offices 5B111, 5B113 Oxygen Left of 5C112 Yes No No gauges 5 Offices 5B111, 5B113 Vacuum Left of 5B112 Yes No No gauges 5 Offices 5B111, 5B113 Medical Air Left of 5B112 Yes No No gauges

5 Cath Lab 5D101, 103, 106, 110 Oxygen Left of 5D103 Yes No Multiple anesthetizing locations combined on a single set of zone valves, No gauges

5 Cath Lab 5D101, 103, 106, 110 Vacuum Left of 5D103 Yes No Multiple anesthetizing locations combined on a single set of zone valves, No gauges

5 Cath Lab 5D101, 103, 106, 110 Medical Air Left of 5D103 Yes No Multiple anesthetizing locations combined on a single set of zone valves, No gauges

Floor Department Controls Gases Location Labeled Ports Notes

G A-G Ward

AG26, 31, 34-36, 38-43, 45, 51,

59 Oxygen Right of AG38 Yes No No gauges

G A-G Ward

AG26, 31, 34-36, 38-43, 45, 51,

59 Medical Air Right of AG38 Yes No No gauges

G A-G Ward

AG26, 31, 34-36, 38-43, 45, 51,

59 Vacuum Right of AG38 Yes No No gauges

G A-G Ward AG32 Oxygen Left of AG32 Yes No No gauges, Leaks at stem in the off position G A-G Ward AG32 Medical Air Left of AG32 Yes No No gauges G A-G Ward AG32 Vacuum Left of AG32 Yes No No gauges 1 Angiography Suite A-106 Procedure Room 1 Medical Air Left of A-106 Yes No 1 Angiography Suite A-106 Procedure Room 1 Oxygen Left of A-106 Yes No 1 Angiography Suite A-106 Procedure Room 1 Vacuum Left of A-106 Yes No 1 Angiography Suite Stretcher Alcove A-106J Medical Air Across from A-102A Yes No * Area is under construction 1 Angiography Suite Stretcher Alcove A-106J Oxygen Across from A-102A Yes No * Area is under construction 1 Angiography Suite Stretcher Alcove A-106J Vacuum Across from A-102A Yes No * Area is under construction 1 Angiography Suite A-106C Medical Air Right of A-106C Yes No 1 Angiography Suite A-106C Oxygen Right of A-106C Yes No 1 Angiography Suite A-106C Vacuum Right of A-106C Yes No 1 A-1 Ward A113, 116, 120, 123-132, 138 Oxygen Right of A-125 Yes No No gauges 1 A-1 Ward A113, 116, 120, 123-132, 138 Medical Air Right of A-125 Yes No No gauges 1 A-1 Ward A113, 116, 120, 123-132, 138 Vacuum Right of A-125 Yes No No gauges 1 A-1 Ward A119 Oxygen Left of A-119 Storage Yes No No gauges 1 A-1 Ward A119 Vacuum Left of A-119 Storage Yes No No gauges 1 A-1 Ward A119 Medical Air Left of A-119 Storage Yes No No gauges

2 A-2 Ward A218, 219, 225, 226, 229-236, A238, 239, 244 Oxygen Right of A-231 Yes No No gauges, Leaks at stem in the on position

2 A-2 Ward A218, 219, 225, 226, 229-236, A238, 239, 244 Medical Air Right of A-231 Yes No No gauges, Leaks in the off position

2 A-2 Ward A218, 219, 225, 226, 229-236, A238, 239, 244 Vacuum Right of A-231 Yes No No gauges 2 SCI Clinic 2B117, 118, 120 Oxygen Left of 2B-123 Yes No 2 SCI Clinic 2B117, 118, 120 Medical Air Left of 2B-123 Yes No 2 SCI Clinic 2B117, 118, 120 Vacuum Left of 2B-123 Yes No 3 Surgical Services OR 1 Oxygen Right of OR 1 Yes No No gauges 3 Surgical Services OR 1 Nitrous Oxide Right of OR 1 Yes No No gauges, Not in service 3 Surgical Services OR 1 Vacuum Right of OR 1 Yes No No gauges, No dedicated WAGD inlet 3 Surgical Services OR 1 Medical Air Right of OR 1 Yes No No gauges

Floor Department Controls Gases Location Labeled Ports Notes 3 Surgical Services OR 2 Oxygen Right of OR 2 Yes No No gauges 3 Surgical Services OR 2 Nitrous Oxide Right of OR 2 Yes No No gauges, Not in service 3 Surgical Services OR 2 Vacuum Right of OR 2 Yes No No gauges, No dedicated WAGD inlet 3 Surgical Services OR 2 Medical Air Right of OR 2 Yes No No gauges 3 Surgical Services OR 3 Oxygen Left of OR 3 Yes No No gauges, Leaks in the off position 3 Surgical Services OR 3 Nitrous Oxide Left of OR 3 Yes No No gauges, Not in service 3 Surgical Services OR 3 Vacuum Left of OR 3 Yes No No gauges, No dedicated WAGD inlet 3 Surgical Services OR 3 Medical Air Left of OR 3 Yes No No gauges, leaks in the off position 3 Surgical Services OR 4 Oxygen Left of OR 4 Yes No No gauges, leaks in the off position

3 Surgical Services OR 4 Nitrous Oxide Left of OR 4 Yes No No gauges, No dedicated WAGD inlet,Not in service

3 Surgical Services OR 4 Vacuum Left of OR 4 Yes No No gauges 3 Surgical Services OR 4 Medical Air Left of OR 4 Yes No No gauges 3 Surgical Services OR 5 Oxygen Right of OR 5 Yes No 3 Surgical Services OR 5 Nitrous Oxide Right of OR 5 Yes No Not in service 3 Surgical Services OR 5 Medical Air Right of OR 5 Yes No 3 Surgical Services OR 5 Vacuum Right of OR 5 Yes No No dedicated WAGD inlet 3 Surgical Services OR 6 Nitrogen Left of OR 6 Yes No Not in service 3 Surgical Services OR 6 Carbon Dioxide Left of OR 6 Yes No Not in service 3 Surgical Services OR 6 Nitrous Oxide Left of OR 6 Yes No Not in service 3 Surgical Services OR 6 Medical Air Left of OR 6 Yes No 51 3 Surgical Services OR 6 Oxygen Left of OR 6 Yes No 50 3 Surgical Services OR 6 WAGD Left of OR 6 Yes No 23 3 Surgical Services OR 6 Vacuum Left of OR 6 Yes No 23, Lost all 3 SICU Beds 1-6 Medical Air Left of SICU entrance Yes Yes 3 SICU Beds 1-6 Oxygen Left of SICU entrance Yes Yes 3 SICU Beds 1-6 Vacuum Left of SICU entrance Yes Yes 3 SICU Beds 7-8 Medical Air Right of Bed 7 Yes Yes 3 SICU Beds 7-8 Oxygen Right of Bed 7 Yes Yes 3 SICU Beds 7-8 Vacuum Right of Bed 7 Yes Yes

Floor Department Controls Gases Location Labeled Ports Notes G Vascular Lab GD117 Medical Air Right of GD117 Yes No G Vascular Lab GD117 Oxygen Right of GD117 Yes No G Vascular Lab GD117 Vacuum Right of GD117 Yes No G Emergency Department ED 1-7, 11-13 Oxygen Across from Room 8 Yes No G Emergency Department ED 1-7, 11-13 Medical Air Across from Room 8 Yes No G Emergency Department ED 1-7, 11-13 Vacuum Across from Room 8 Yes No G X-Ray/Specialty Clinic GA106, 113, 116A, 119 Oxygen Left of GA100 Yes No G X-Ray/Specialty Clinic GA106, 113, 116A, 119 Medical Air Left of GA100 Yes No G X-Ray/Specialty Clinic GA106, 113, 116A, 119 Vacuum Left of GA100 Yes Yes No gauge G Personnel Security GB105A Oxygen Inside GB105A Yes No Zone valve inside room G Personnel Security GB105A Medical Air Inside GB105A Yes No Zone valve inside room G Personnel Security GB105A Vacuum Inside GB105A Yes No Zone valve inside room G Nuclear Medicine 2C111, 113, 115, 118, 128 Medical Air Loading Dock Hallway Yes No Controls zones on 2nd floor G Nuclear Medicine 2C111, 113, 115, 118, 128 Oxygen Loading Dock Hallway Yes No Controls zones on 2nd floor G Nuclear Medicine 2C111, 113, 115, 118, 128 Vacuum Loading Dock Hallway Yes No Controls zones on 2nd floor 2 Nuclear Medicine 2C113, 115, 118 Medical Air Right of 2C-118 Yes No Redundant 2 Nuclear Medicine 2C113, 115, 118 Oxygen Right of 2C-118 Yes No Redundant 2 Nuclear Medicine 2C113, 115, 118 Vacuum Right of 2C-118 Yes No Redundant 2 Nuclear Medicine 2C111, 128 Oxygen Right of 2C-111 Yes No Redundant 2 Nuclear Medicine 2C111 Medical Air Right of 2C-111 Yes No Redundant 2 Nuclear Medicine 2C111 Vacuum Right of 2C-111 Yes No Redundant

Outlets/Inlet Testing

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes Pulmonary G GB118D 500 AHC Oxygen Pass No zone valve

500 AHC Medical Air Pass No zone valve Pulmonary G GB118E 500 AHC Oxygen Pass No zone valve

500 AHC Medical Air Pass No zone valve Pulmonary G GB140 500 AHC Oxygen Pass

500 AHC Medical Air Pass 500 AHC Vacuum Pass

Pulmonary G GB141A 500 AHC Vacuum Pass 500 AHC Medical Air Pass 500 AHC Oxygen Pass

Pulmonary G GB144 500 AHC Oxygen Pass 500 AHC Medical Air Pass 500 AHC Vacuum Pass

Pulmonary G GB146 500 AHC Oxygen N/A Labeled Not in Service 500 AHC Medical Air Pass 500 AHC Vacuum Pass

Clinical Engineering G GB115 500 AHC Oxygen Pass No zone valve Series B AHC Medical Air Pass No zone valve Series B AHC Vacuum Pass No zone valve Series B AHC Oxygen Pass No zone valve Series B AHC Medical Air Pass No zone valve Series B AHC Vacuum Pass No zone valve

Turret Vacuum N/A No zone valve Turret AHC Medical Air Pass No zone valve

500 AHC Oxygen Pass No zone valve 500 AHC Oxygen Pass No zone valve

Turret Medical Air N/A No zone valve Turret Vacuum N/A No zone valve

Turret AHC Vacuum Pass No zone valve Turret Medical Air N/A No zone valve

500 AHC Oxygen Pass No zone valve MRI G GB152 500 AHC Vacuum Pass

500 AHC Medical Air Pass 500 AHC Oxygen Pass 500 AHC Vacuum Pass 500 AHC Medical Air Pass 500 AHC Oxygen Pass

MRI G GB154 500 AHC Vacuum Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes 500 AHC Medical Air Pass 500 AHC Oxygen Pass

MRI G GB174 500 AHC Vacuum Pass 500 AHC Medical Air Pass 500 AHC Oxygen Pass

CT Scan G GB102 500 AHC Oxygen Pass Particulate 500 AHC Medical Air Pass DP -29.2 500 AHC Vacuum Pass

CT Scan G GB103 500 AHC Oxygen Pass 500 AHC Medical Air Pass 500 AHC Vacuum Pass

CT Scan G GB105 500 AHC Oxygen Pass 500 AHC Medical Air Pass 500 AHC Vacuum Pass

EEG 1 1D135 500 AHC Oxygen Pass 500 AHC Vacuum Pass No zone valve

EEG 1 1D136 500 AHC Vacuum Pass No zone valve 500 AHC Oxygen Pass

EEG 1 1D138 500 AHC Oxygen Pass 500 AHC Vacuum Pass No zone valve 500 AHC Vacuum Pass No zone valve 500 AHC Oxygen Pass

Cardiology 1 1D108 500 AHC Vacuum Pass No zone valve 500 AHC Vacuum Pass No zone valve

Cardiology 1 1D109 500 AHC Vacuum Pass No zone valve 500 AHC Vacuum Pass No zone valve

Cardiology 1 1D110 500 AHC Vacuum Pass No zone valve 500 AHC Vacuum Pass No zone valve

Cardiology 1 1D111 500 AHC Vacuum Pass No zone valve 500 AHC Vacuum Pass No zone valve

Cardiology 1 1D115 500 AHC Vacuum Pass No zone valve 500 AHC Vacuum Pass No zone valve

Cardiology 1 1D116 500 AHC Vacuum Pass No zone valve 500 AHC Vacuum Pass No zone valve

Cardiology 1 1D117 500 AHC Vacuum Pass No zone valve 500 AHC Vacuum Pass No zone valve

Cardiology 1 1D119 500 AHC Vacuum Pass No zone valve

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes 500 AHC Vacuum Pass No zone valve

Cardiology 1 1D120 500 AHC Vacuum Pass No zone valve 500 AHC Vacuum Pass No zone valve

Radiology 1 1B108 500 AHC Oxygen Pass 500 AHC Medical Air Pass 500 AHC Vacuum Pass

Radiology 1 1B109 Series B AHC Vacuum Pass Series B AHC Medical Air Pass Series B AHC Oxygen Pass

Radiology 1 1B113 500 AHC Oxygen Pass Particulate 500 AHC Medical Air Pass DP -27.8 500 AHC Vacuum Pass

Radiology 1 1B117 500 AHC Oxygen Pass 500 AHC Medical Air Pass 500 AHC Vacuum Pass

Radiology 1 1B142 400 AHC Medical Air Pass 400 AHC Oxygen Pass 400 AHC Vacuum Pass

Radiology 1 1B146 500 AHC Medical Air Pass 500 AHC Oxygen Pass 500 AHC Vacuum Pass

Endoscopy 1 1B148 500 AHC Oxygen Pass 500 AHC Medical Air Pass 500 AHC Vacuum Pass 500 AHC Vacuum Pass

Endoscopy 1 1B155 500 AHC Vacuum Pass 500 AHC Vacuum Pass 500 AHC Medical Air Pass 500 AHC Oxygen Pass

Endoscopy 1 1B156A 500 AHC Oxygen Pass 500 AHC Medical Air Pass 500 AHC Vacuum Pass 500 AHC Vacuum Pass

Endoscopy 1 1B157B 500 AHC Oxygen Pass 500 AHC Medical Air Pass 500 AHC Vacuum Pass 500 AHC Vacuum Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes Endoscopy 1 1B160 500 AHC Oxygen Pass

500 AHC Medical Air Pass 500 AHC Vacuum Pass 500 AHC Vacuum Pass

2 South 2 2B104 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B105 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B108 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B109 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass

2 South 2 2B111 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B112 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B129 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B130 400 AHC Oxygen N/A Covid 400 AHC Medical Air N/A Covid 400 AHC Vacuum N/A Covid

2 South 2 2B131 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B133 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass

2 South 2 2B134 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B135 400 AHC Oxygen N/A Covid 400 AHC Medical Air N/A Covid 400 AHC Vacuum N/A Covid

2 South 2 2B136 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B140 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B141 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass

2 South 2 2B142 400 AHC Oxygen Pass 400 AHC Medical Air Pass

2 North 2 2D103 Amico AHC Vacuum Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes Amico AHC Medical Air Pass Amico AHC Oxygen Pass Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D104 Amico AHC Vacuum Pass Amico AHC Medical Air Pass Amico AHC Oxygen Pass Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D107 Amico AHC Vacuum Pass Amico AHC Medical Air Pass Amico AHC Oxygen Pass Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum N/A In use

2 North 2 2D108 Amico AHC Vacuum Pass Amico AHC Medical Air Pass Amico AHC Oxygen N/A In use Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D109 Amico AHC Vacuum Pass Amico AHC Medical Air Pass Amico AHC Oxygen Pass

2 North 2 2D110 Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D111 Amico AHC Vacuum Pass Amico AHC Medical Air Pass Amico AHC Oxygen Pass

2 North 2 2D112 Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D113 Amico AHC Vacuum Pass Amico AHC Medical Air Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes Amico AHC Oxygen Pass

2 North 2 2D114 Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D118 Amico AHC Vacuum Pass Amico AHC Medical Air Pass Amico AHC Oxygen Pass Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D119 Amico AHC Vacuum Pass Amico AHC Medical Air Pass Amico AHC Oxygen Pass Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D120 Amico AHC Vacuum Pass Amico AHC Medical Air Pass Amico AHC Oxygen Pass Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D124 Amico AHC Vacuum Pass Amico AHC Medical Air Pass DP -32.8 Amico AHC Oxygen Pass Particulate

2 North 2 2D125 Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D128 Amico AHC Vacuum Pass Amico AHC Medical Air Pass Amico AHC Oxygen Pass Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

2 North 2 2D129 Amico AHC Vacuum Pass

Amico AHC Oxygen Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes Amico AHC Oxygen Pass Amico AHC Medical Air Pass Amico AHC Vacuum Pass

3 North 3 3D102 400 AHC Oxygen Pass 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass

3 North 3 3D103 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass 400 AHC Vacuum N/A In use 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass 400 AHC Medical Air Pass

3 North 3 3D104 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass 400 AHC Vacuum Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass 400 AHC Medical Air Pass

3 North 3 3D108 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass

3 North 3 3D109 400 AHC Oxygen Pass 400 AHC Medical Air Pass

3 North 3 3D110 400 AHC Oxygen Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes 400 AHC Medical Air Pass 400 AHC Vacuum N/A In use

3 North 3 3D111 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass Particulate 400 AHC Medical Air Pass DP -26.2 400 AHC Vacuum Pass

3 North 3 3D112 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen N/A In use 400 AHC Medical Air Pass 400 AHC Vacuum Fail Leaks

3 North 3 3D114 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass

3 North 3 3D115 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum N/A In use

3 North 3 3D116 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass

3 North 3 3D117 400 AHC Oxygen N/A In use 400 AHC Medical Air N/A In use 400 AHC Vacuum N/A In use

3 North 3 3D118 (Soiled

Utility) 400 AHC Oxygen Pass 400 AHC Medical Air Pass

3 North 3 3D119 400 AHC Oxygen Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen N/A In use 400 AHC Medical Air Pass 400 AHC Vacuum Pass

3 North 3 3D142 400 AHC Oxygen Pass 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass 400 AHC Vacuum N/A In use 400 AHC Medical Air Pass 400 AHC Vacuum Pass 400 AHC Oxygen Pass 400 AHC Medical Air Pass

PACU 3 Room 1 Series B AHC Oxygen Pass Series B AHC Medical Air Pass Series B AHC Oxygen Pass Series B AHC Vacuum Pass Series B AHC Oxygen Pass Series B AHC Vacuum Pass Series B AHC Vacuum Pass Series B AHC Vacuum Pass

PACU 3 Bay 2 Series B AHC Vacuum Pass Series B AHC Vacuum Pass Series B AHC Oxygen Pass Series B AHC Oxygen Pass Series B AHC Oxygen Pass Series B AHC Medical Air Pass Series B AHC Vacuum Pass Series B AHC Vacuum Pass

PACU 3 Bay 3 Series B AHC Vacuum Pass Series B AHC Vacuum Pass Series B AHC Oxygen Pass Series B AHC Oxygen Pass Series B AHC Oxygen Pass Series B AHC Medical Air Pass Series B AHC Vacuum Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes Series B AHC Vacuum Pass

PACU 3 Bay 4 Series B AHC Vacuum Pass Series B AHC Vacuum Pass Series B AHC Oxygen Pass Series B AHC Oxygen Pass Series B AHC Oxygen Pass Series B AHC Medical Air Pass Series B AHC Vacuum Pass Series B AHC Vacuum Pass

PACU 3 Bay 5 Series B AHC Vacuum Pass Series B AHC Vacuum Pass Series B AHC Oxygen Pass Series B AHC Oxygen Pass Series B AHC Oxygen…