Jan 2023 VA JP Annual Inspection OR_Redacted.pdf

2023 Medical Gas Testing and Evaluation

Testing Completed January 28, 2023

January 29, 2023

VAMC Jamaica Plain 150 South Huntington Street

Jamaica Plain, MA 02130

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 Discrepancies

Summary Compliance Discrepancies

Summary General Comments

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 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 NFPA 99, 2021 edition Health Care Facilities Code 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, 2021 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 UNLESS THE AUTHORITY

HAVING JURISDICTION HAS DETERMINED THAT SUCH USE CONSTITUTES A

DISTINCT HAZARD TO LIFE.

This report also may satisfy any preventative maintenance requirement from the Department of Health or The Joint Commission. Please note that our methodology constantly changes to meet any changes in NFPA and The Joint Commission 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, 2021 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.

1. Inventoried by location

2. Tested by removing existing pressure switches and other sensing devices to test the actuation points. No interruption of service is necessary as long as 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. (Due to the continuing COVID-19 Pandemic, we will not be testing the outlets/inlets in any Airborne or Droplet precaution rooms)

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, 2021 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 possible 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 insure 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, 2021 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

Urgent Care 1 1 3 91 91

ASU/ISOL 3 1 3 128 128

PACU 3 1 3 56 56

Surgical Services 3 1 48 226 226

Master Alarm B 2

Total Count: 6 57 501 501 100% Tested

INVENTORY OF MEDICAL GAS COMPONENTS

VA Medical Center Jamaica Plain

SUMMARY OF MAINTENANCE DEFICIENCIES

Urgent Care

1. Area alarm located at the nurse’s station had the oxygen low pressure alarm at 38 psig, medical air low pressure alarm at 38 psig, and vacuum low alarm at 8” Hg.

2. Station 1:

a. 1st oxygen outlet leaks.

b. 2nd vacuum inlet has a defective latch.

ASU/ISOL

2. Bay 12 – 1st oxygen outlet has a damaged assembly which needs replacement.

PACU

2. Bay 1 – Even though the particulate sample taken from this location passed for weight per NFPA criteria, it was visibly soiled.

3. Bay 5 – 2nd vacuum inlet has a damaged latch.

Surgical Services

1. Operating Room 2 – During the 10-minute standing pressure test, vacuum lost 20” Hg.

2. Operating Room 3 – During the 10-minute standing pressure test, nitrogen lost 10 psig.

3. Operating Room 4 – WAGD inlet on the wall leaks with the adapter attached.

4. Operating Room 5 – During the 10-minute standing pressure test, nitrogen lost 10

SUMMARY OF MAINTENANCE DEFICIENCIES

5. Operating Room 7 – During the 10-minute standing pressure test, nitrogen lost 35

Sources

1. Nitrous Oxide Manifold – There was a leak located at the high/low pressure switch demand check.

2. Nitrogen Manifold – There was a leak located at the high/low pressure switch demand check.

SUMMARY OF COMPLIANCE DEFICIENCIES

Urgent Care

1. Area alarm located at the nurse’s station does not have separate visual indicators for each condition monitored.1

2. Zone valves located right of entrance do not have threaded purge ports on the patient side and source side.2

ASU/ISOL

each condition monitored.3

2. Zone valves located right of F3-29 ASU do not have threaded purge ports on the patient side and source side.4

PACU

each condition monitored.5

2. Zone valves located right of F3-13 PACU do not have threaded purge ports on the patient side and source side.6

Surgical Services

1. All zone valves located in this department do not have threaded purge ports on the patient side and source side.7

2. Because the station outlets/inlets (not including Nitrogen) on the columns in

Operating Rooms 1-8 are installed in a down-facing position, the outlets/inlets need to be DISS connectors.8

1. Oxygen Supply System:

a. The outdoor bulk cryogenic liquid system needs to be provided with a minimum of two entry/exits.9

b. Source valve needs to be relabeled with the name for the specific medical gas, rooms or areas served, and caution to not close or open the valve except in emergency.10

c. Auxiliary valve needs to be labeled with the name for the specific medical gas, rooms or areas served, and caution to not close or open the valve except in emergency.11

d. Does not have permanent guard posts installed around the bulk pad site.12

e. Source equipment needs to be labeled with the name color code of gas or vacuum system, areas served and emergency contact information for the department or individual responsible for maintaining the equipment.13

2. Emergency Oxygen Supply Connection:

a. There are no alarms installed at the master alarms allowing the temporary oxygen supply to be monitored while in use.14

b. Pressure relief vent line is not labeled in accordance with 5.1.11.1 to distinguish itself from the medical gas pipeline.15

3. Nitrous Oxide Manifold:

a. Source valve has threaded connections on each side of the valve and not factory brazed extensions.16

b. Service valve located outside the manifold room door has threaded connections on each side of the valve and not factory brazed extensions.17

c. After the source valve there are multiple threaded plugs on the pipeline.18

d. Source equipment needs to be labeled with the name color code of gas or vacuum system, areas served and emergency contact information for the department or individual responsible for maintaining the equipment.19

e. Pressure relief vent line is not labeled on the roof in accordance with 5.1.11.1 to distinguish itself from the medical gas pipeline.20

4. Nitrogen Manifold:

a. Service valve located outside the manifold room door has threaded connections on each side of the valve and not factory brazed extensions.21

b. Source equipment needs to be labeled with the name color code of gas or vacuum system, areas served and emergency contact information for the department or individual responsible for maintaining the equipment.22

c. Pressure relief vent line is not labeled on the roof in accordance with 5.1.11.1 to distinguish itself from the medical gas pipeline.23

5. Medical Air Compressor:

a. The main supply piping that is in the vacuum pump room is painted.24

b. Source equipment needs to be labeled with the name color code of gas or department or individual responsible for maintaining the equipment.25

6. Vacuum Pump:

a. Source equipment needs to be labeled with the name color code of gas or department or individual responsible for maintaining the equipment.26

b. 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.27

c. Vacuum exhaust piping located inside SBE24 needs to be relabeled in accordance with 5.1.11.1 with any method that would distinguish it as a vacuum exhaust.28

d. Vacuum piping needs to be relabeled with compliant pipe labels.29

1 NFPA 99, 2021 edition paragraph 5.1.9.1 (1)

2 NFPA 99, 2021 edition paragraph 5.1.4.1.6 (8)

3 NFPA 99, 2021 edition paragraph 5.1.9.1 (1)

4 NFPA 99, 2021 edition paragraph 5.1.4.1.6 (8)

5 NFPA 99, 2021 edition paragraph 5.1.9.1 (1)

6 NFPA 99, 2021 edition paragraph 5.1.4.1.6 (8)

7 NFPA 99, 2021 edition paragraph 5.1.4.1.6 (8)

8 NFPA 99, 2021 edition paragraph 5.1.5.17

9 NFPA 99, 2021 edition paragraph 5.1.3.10.2.6, NFPA 55, 2020 edition chapters 8 & 9, and CGA M-1 paragraph 8.3.

10 NFPA 99, 2021 edition paragraph 5.1.11.2.1 and 5.1.11.2.4

11 NFPA 99, 2021 edition paragraph 5.1.11.2.1 and 5.1.11.2.7

12 NFPA 99, 2021 edition paragraph 5.1.3.10.2.6 and NFPA 55, 2020 edition paragraph 8.12.2.3.1 and 4.11.1

13 NFPA 99, 2021 edition paragraph 5.1.11.5.1

14 NFPA 99, 2021 edition paragraph 5.1.3.5.13.2 (8)

15 NFPA 99, 2021 edition paragraph 5.1.3.5.6.5

16 NFPA 99, 2021 edition paragraph 5.1.4.1.6 (4) and 5.1.10.10 (2)

17 NFPA 99, 2021 edition paragraph 5.1.4.1.6 (4) and 5.1.10.10 (2)

18 NFPA 99, 2021 edition paragraph 5.1.10.8 and 5.1.10.10 (2)

19 NFPA 99, 2021 edition paragraph 5.1.11.5.1

20 NFPA 99, 2021 edition paragraph 5.1.3.5.6.5

21 NFPA 99, 2021 edition paragraph 5.1.4.1.6 (4) and 5.1.10.10 (2)

22 NFPA 99, 2021 edition paragraph 5.1.11.5.1

23 NFPA 99, 2021 edition paragraph 5.1.3.5.6.5

24 NFPA 99, 2021 edition paragraph 5.1.11.1.5

25 NFPA 99, 2021 edition paragraph 5.1.11.5.1

26 NFPA 99, 2021 edition paragraph 5.1.11.5.1

27 NFPA 99, 2021 edition paragraph 5.1.11.5.2

28 NFPA 99, 2021 edition paragraph 5.1.3.7.7.4

29 NFPA 99, 2021 edition paragraph 5.1.11.1.1 (2)

SUMMARY OF GENERAL COMMENTS

1. 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

2. 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.

3. The locations of the medical air intake piping and vacuum exhaust piping were unable to be located on the roof, therefore each were not able to be inspected for proper compliance.

4. recommends having the oxygen supplier adjust the line pressure to the required 50-55 psig range. Currently the pressure is at 58 psig which is slightly outside the required range.1

1 NFPA 99, 2021 edition paragraph 5.1.12.4.10.2 and Table 5.1.11

Alarm Testing

Floor Monitors Department Location Labeled Pass/Fail Comment B All Sources (Master) Facilities Boiler Plant Yes Pass B All Sources (Master) Facilities Carpenters Shop BB30 Yes Pass

1 Station 1-12, 14 Urgent Care Nurses' Station Yes Fail Oxy 38, Med air 38, Vac 8, Non-separate visual indicators

3 Bay 1-14 ASU/ISOL Nurses' Station Yes Fail Oxy 38, Med air 38, Vac 8, Non-separate visual indicators

3 Bays 1-7 PACU Nurses' Station Yes Fail Oxy 38, Med air 38, Vac 8, Non-separate visual indicators

3 Operating Rooms 1-8 Surgical Services Nurses' Station Yes Pass

Master Alarm Testing Results

Source Line Pressure High Pressure Low Pressure Secondary Oxygen 58 psig 63 psig 44 psig N/A

Nitrous Oxide 48 psig 59 psig 41 psig Pass Nitrogen 170 psig 180 psig 140 psig Pass

Medical Air 51 psig 62 psig 42 psig Pass CO - Passed, DP - Passed Vacuum -20" Hg N/A -11" Hg Pass

Zone Valve Testing

Floor Department Controls Gases Location Labeled Ports Notes 1 Urgent Care Station 1-12, 14 Oxygen Right of Entrance to ED Yes No 1 Urgent Care Station 1-12, 14 Medical Air Right of Entrance to ED Yes No 1 Urgent Care Station 1-12, 14 Vacuum Right of Entrance to ED Yes No 3 ASU/ISOL Bays 1-14 Oxygen Right of F3-29 ASU Yes No 3 ASU/ISOL Bays 1-14 Medical Air Right of F3-29 ASU Yes No 3 ASU/ISOL Bays 1-14 Vacuum Right of F3-29 ASU Yes No 3 PACU Bays 1-7 Oxygen Right of F3-13 PACU Yes No 3 PACU Bays 1-7 Medical Air Right of F3-13 PACU Yes No 3 PACU Bays 1-7 Vacuum Right of F3-13 PACU Yes No 3 Surgical Services OR 1 Nitrous Oxide Right of OR 1 Yes No 48 3 Surgical Services OR 1 Oxygen Right of OR 1 Yes No 57 3 Surgical Services OR 1 Medical Air Right of OR 1 Yes No 50 3 Surgical Services OR 1 Nitrogen Right of OR 1 Yes No 160 3 Surgical Services OR 1 WAGD Right of OR 1 Yes No 21 3 Surgical Services OR 1 Vacuum Right of OR 1 Yes No 20 3 Surgical Services OR 2 Nitrous Oxide Right of OR 2 Yes No 48 3 Surgical Services OR 2 Oxygen Right of OR 2 Yes No 58 3 Surgical Services OR 2 Medical Air Right of OR 2 Yes No 50 3 Surgical Services OR 2 Nitrogen Right of OR 2 Yes No 165 3 Surgical Services OR 2 WAGD Right of OR 2 Yes No 19 3 Surgical Services OR 2 Vacuum Right of OR 2 Yes No 20, lost all 3 Surgical Services OR 3 Nitrous Oxide Right of OR 3 Yes No 48 3 Surgical Services OR 3 Oxygen Right of OR 3 Yes No 58 3 Surgical Services OR 3 Medical Air Right of OR 3 Yes No 50 3 Surgical Services OR 3 Nitrogen Right of OR 3 Yes No 165, lost 10 3 Surgical Services OR 3 WAGD Right of OR 3 Yes No 23 3 Surgical Services OR 3 Vacuum Right of OR 3 Yes No 22 3 Surgical Services OR 4 Nitrous Oxide Left of OR 4 Yes No 48 3 Surgical Services OR 4 Oxygen Left of OR 4 Yes No 56 3 Surgical Services OR 4 Medical Air Left of OR 4 Yes No 50 3 Surgical Services OR 4 Nitrogen Left of OR 4 Yes No 165 3 Surgical Services OR 4 WAGD Left of OR 4 Yes No 21 3 Surgical Services OR 4 Vacuum Left of OR 4 Yes No 21 3 Surgical Services OR 5 WAGD Left of OR 5 Yes No 24 3 Surgical Services OR 5 Vacuum Left of OR 5 Yes No 24 3 Surgical Services OR 5 Nitrous Oxide Left of OR 5 Yes No 48 3 Surgical Services OR 5 Oxygen Left of OR 5 Yes No 58

Zone Valve Testing

Floor Department Controls Gases Location Labeled Ports Notes 3 Surgical Services OR 5 Medical Air Left of OR 5 Yes No 51 3 Surgical Services OR 5 Nitrogen Left of OR 5 Yes No 162, lost 10 3 Surgical Services OR 6 WAGD Left of OR 6 Yes No 21 3 Surgical Services OR 6 Vacuum Left of OR 6 Yes No 21 3 Surgical Services OR 6 Nitrous Oxide Left of OR 6 Yes No 47 3 Surgical Services OR 6 Oxygen Left of OR 6 Yes No 56 3 Surgical Services OR 6 Medical Air Left of OR 6 Yes No 50 3 Surgical Services OR 6 Nitrogen Left of OR 6 Yes No 165 3 Surgical Services OR 7 WAGD Right of OR 7 Yes No 25 3 Surgical Services OR 7 Vacuum Right of OR 7 Yes No 25 3 Surgical Services OR 7 Nitrous Oxide Right of OR 7 Yes No 48 3 Surgical Services OR7 Oxygen Right of OR 7 Yes No 56 3 Surgical Services OR 7 Medical Air Right of OR 7 Yes No 50 3 Surgical Services OR 7 Nitrogen Right of OR 7 Yes No 160, lost 35 3 Surgical Services OR 8/Cysto WAGD Left of OR 8 Yes No 22.5 3 Surgical Services OR 8/Cysto Vacuum Left of OR 8 Yes No 22.5 3 Surgical Services OR 8/Cysto Nitrous Oxide Left of OR 8 Yes No 46 3 Surgical Services OR 8/Cysto Oxygen Left of OR 8 Yes No 58 3 Surgical Services OR 8/Cysto Medical Air Left of OR 8 Yes No 50 3 Surgical Services OR 8/Cysto Nitrogen Left of OR 8 Yes No 160

Outlets/Inlet Testing

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes Urgent Care 1 Station 1 AHC - 400 Medical Air Pass

AHC - 400 Oxygen Fail Leaks AHC - 400 Vacuum Pass AHC - 400 Vacuum Fail Defective latch

AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass

AHC - 400 Medical Air Pass Urgent Care 1 Station 2 AHC - 400 Medical Air Pass

AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

Urgent Care 1 Station 3 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

Urgent Care 1 Station 4 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

Urgent Care 1 Station 5 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

Urgent Care 1 Station 6 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass

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

Urgent Care 1 Station 7 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

Urgent Care 1 Station 8 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

Urgent Care 1 Station 9 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

Urgent Care 1 Station 10 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

Urgent Care 1 Station 11 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass

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

Urgent Care 1 Station 12 AHC - 400 Medical Air Pass DP -0.4 AHC - 400 Oxygen Pass Particulate test (.0705g) AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

Urgent Care 1 Station 14 AHC - 400 Medical Air Pass AHC - 400 Oxygen Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Vacuum Pass AHC - 400 Oxygen Pass AHC - 400 Medical Air Pass

ASU/ISOL 3 Bay 1 AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass

ASU/ISOL 3 Bay 2 AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes ASU/ISOL 3 Bay 3 AHC - Hill Rom Vacuum Pass

AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass

ASU/ISOL 3 Bay 4 AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass

ASU/ISOL 3 Bay 5 AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass

ASU/ISOL 3 Bay 6 AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass

ASU/ISOL 3 Bay 7 AHC - Hill Rom Vacuum Pass

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

ASU/ISOL 3 Bay 8 AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass

ASU/ISOL 3 Bay 9 AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Medical Air Pass

ASU/ISOL 3 Bay 10 AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Medical Air Pass

ASU/ISOL 3 Bay 11 AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass

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

ASU/ISOL 3 Bay 12 AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Fail Damaged assembly, needs replacement AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass

ASU/ISOL 3 Bay 13 AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass

ASU/ISOL 3 Bay 14 AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass

PACU 3 Bay 1 AHC - Hill Rom Oxygen Pass Particulate Test (.0729g) Visibly Soiled AHC - Hill Rom Medical Air Pass DP +1.0

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

PACU 3 Bay 2 AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass

PACU 3 Bay 3 AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Vacuum Pass

PACU 3 Bay 4 AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass

PACU 3 Bay 5 AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass Damaged latch AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes PACU 3 Bay 6 AHC - Hill Rom Vacuum Pass

AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Medical Air Pass

PACU 3 Bay 7 AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Vacuum Pass AHC - Hill Rom Oxygen Pass AHC - Hill Rom Medical Air Pass AHC - Hill Rom Vacuum Pass

Surgical Services 3 Operating Room 1 DISS - Beacon Nitrogen Pass Panel AHC - 500 Vacuum Pass Wall AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Medical Air Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass AHC - 500 Oxygen Pass AHC - 500 Oxygen Pass DISS - 560 Nitrogen Pass AHC - 500 WAGD Pass AHC - 500 Nitrous Oxide Pass

AHC - 489M Coupler Oxygen Pass Column, downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes AHC - 489M Coupler Vacuum Pass Downward facing AHC DISS - 489M Coupler Nitrogen Pass DISS - 489M Coupler Nitrogen Pass AHC - 489M Coupler Oxygen Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler WAGD Pass Downward facing AHC AHC - 489M Coupler Nitrous Oxide Pass Downward facing AHC

Surgical Services 3 Operating Room 2 AHC - 500 Medical Air Pass Wall AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass AHC - 500 Oxygen Pass AHC - 500 Oxygen Pass DISS - 560 Nitrogen Pass AHC - 500 WAGD Pass AHC - 500 Nitrous Oxide Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass

DISS - Medaes Nitrogen Pass Panel AHC - 489M Coupler Oxygen Pass Column, downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC DISS - 489M Coupler Nitrogen Pass DISS - 489M Coupler Nitrogen Pass AHC - 489M Coupler Oxygen Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC

AHC - 489M Coupler WAGD Pass Downward facing AHC

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes AHC - 489M Coupler Nitrous Oxide Pass Downward facing AHC

Surgical Services 3 Operating Room 3 DISS - Medaes Nitrogen Pass Panel AHC - 500 Vacuum Pass Wall AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Medical Air Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass AHC - 500 Oxygen Pass AHC - 500 Oxygen Pass DISS - 560 Nitrogen Pass AHC - 500 WAGD Pass AHC - 500 Nitrous Oxide Pass

AHC - 489M Coupler Oxygen Pass Column, downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC DISS - 489M Coupler Nitrogen Pass DISS - 489M Coupler Nitrogen Pass AHC - 489M Coupler Oxygen Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler WAGD Pass Downward facing AHC AHC - 489M Coupler Nitrous Oxide Pass Downward facing AHC

Surgical Services 3 Operating Room 4 AHC - 500 Medical Air Pass Wall AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass AHC - 500 Oxygen Pass AHC - 500 Oxygen Pass DISS - 560 Nitrogen Pass AHC - 500 WAGD Fail Leaks with adapter attached AHC - 500 Nitrous Oxide Pass AHC - 500 Vacuum Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass

DISS - Medaes Nitrogen Pass Panel AHC - 489M Coupler Oxygen Pass Column, downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC DISS - 489M Coupler Nitrogen Pass DISS - 489M Coupler Nitrogen Pass AHC - 489M Coupler Oxygen Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler WAGD Pass Downward facing AHC AHC - 489M Coupler Nitrous Oxide Pass Downward facing AHC

Surgical Services 3 Operating Room 5 DISS - Medaes Nitrogen Pass Panel AHC - 500 Vacuum Pass Wall AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Medical Air Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass AHC - 500 Oxygen Pass AHC - 500 Oxygen Pass DISS - 560 Nitrogen Pass AHC - 500 WAGD Pass AHC - 500 Nitrous Oxide Pass

AHC - 489M Coupler Oxygen Pass Column, downward facing AHC

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC DISS - 489M Coupler Nitrogen Pass DISS - 489M Coupler Nitrogen Pass AHC - 489M Coupler Oxygen Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler WAGD Pass Downward facing AHC AHC - 489M Coupler Nitrous Oxide Pass Downward facing AHC

Surgical Services 3 Operating Room 6 AHC - 500 Medical Air Pass Wall AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass AHC - 500 Oxygen Pass AHC - 500 Oxygen Pass DISS - 560 Nitrogen Pass AHC - 500 WAGD Pass AHC - 500 Nitrous Oxide Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Vacuum N/A Not in service AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass

DISS - Medaes Nitrogen Pass Panel AHC - 489M Coupler Oxygen Pass Column, downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC DISS - 489M Coupler Nitrogen Pass DISS - 489M Coupler Nitrogen Pass AHC - 489M Coupler Oxygen Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler WAGD Pass Downward facing AHC AHC - 489M Coupler Nitrous Oxide Pass Downward facing AHC

Surgical Services 3 Operating Room 7 AHC - 500 Vacuum Pass Wall AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass AHC - 500 Medical Air Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass AHC - 500 Oxygen Pass AHC - 500 Oxygen Pass DISS - 560 Nitrogen Pass AHC - 500 WAGD Pass AHC - 500 Nitrous Oxide Pass

DISS - Medaes Nitrogen Pass Panel AHC - 500 Vacuum Pass Wall AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass

AHC - 489M Coupler Oxygen Pass Column, downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC DISS - 489M Coupler Nitrogen Pass DISS - 489M Coupler Nitrogen Pass AHC - 489M Coupler Oxygen Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler WAGD Pass Downward facing AHC AHC - 489M Coupler Nitrous Oxide Pass Downward facing AHC

Surgical Services 3 Operating Room 8 AHC - 500 Vacuum Pass Wall AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass

DISS - Beacon Nitrogen Pass Panel AHC - 500 Medical Air Pass

Department Floor Room # Outlet Type Outlet/Inlet Pass/Fail Notes AHC - 500 Oxygen Pass AHC - 500 Oxygen Pass DISS - 560 Nitrogen Pass AHC - 500 WAGD Pass AHC - 500 Nitrous Oxide Pass AHC - 500 Vacuum Pass AHC - 500 Vacuum Pass DISS - 560 Nitrogen Pass

AHC - 489M Coupler Oxygen Pass Column, downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC DISS - 489M Coupler Nitrogen Pass DISS - 489M Coupler Nitrogen Pass AHC - 489M Coupler Oxygen Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Medical Air Pass Downward facing AHC AHC - 489M Coupler Vacuum Pass Downward facing AHC AHC - 489M Coupler WAGD Pass Downward facing AHC AHC - 489M Coupler Nitrous Oxide Pass Downward facing AHC

Floor Source Manufacturer Location Notes Outside Oxygen Supply System Airgas Across from Shuttle Entrance One gate on bulk pad

Source valve needs to be relabeled Auxiliary valve needs to be labeled No permanent protection at bulk site The source equipment needs to be labeled (2021)

SB

Oxygen Supply System

(In-House Components) N/A Plumbers Cage

Outside EOSC N/A Left of Shuttle Entrance Four alarm connection points installed to both master alarm panels (2021) Pressure relief vent line not labeled

4F Nitrous Oxide Manifold Medaes 3000 ACA Building Room 4F Source valve has threaded extensions Service valve has threaded extension (Outside door) Threaded plugs after source valve The source equipment needs to be labeled (2021) Leak at pressure switch demand check Pressure relief vent line not labeled on roof

4F Nitrogen Manifold Medaes 3000 ACA Building Room 4F Service valve has threaded extension (Outside door) The source equipment needs to be labeled (2021) Leak at pressure switch demand check Pressure relief vent line not labeled on roof

SB Medical Air compressor Beacon Medaes SBE 24 DP +0.6 Painted piping in vacuum room The source equipment needs to be labeled (2021) Unable to locate the air intake piping on the roof (General Comment)

SB Vacuum Pump Beacon Medaes SBE 24 The source equipment needs to be labeled (2021) Vacuum source valve needs to additionally be labeled WAGD to indicate both systems (2021) Vacuum piping needs to also be labeled WAGD (2021) Vacuum exhaust needs to be relabeled inside SBE24 Vacuum piping needs to be relabeled proper color Unable to locate the exhaust piping on the roof (General Comment)