Cape Girardeau VA Med Gas Annual 2025.pdf

PREPARED BY: BRAYDEN SEGER

TESTING DATES: SEPTEMBER 29TH, 2025

CAPE GIRARDEAU VA HEALTH CARE CENTER

MEDICAL GAS

ANNUAL

INSPECTION

711 S MT AUBURN RD

CAPE GIRARDEAU, MO

ITEMS TESTED/INSPECTED

OXYGEN MEDICAL AIR

MEDICAL

VACUUM

NITROUS

OXIDE

NITROGEN

CARBON

DIOXIDE

INST. AIR WAGD

SOURCE EQUIPMENT P P P

MASTER ALARMS P P P

ZONE VALVES P P P P

ZONE VERIFICATION P P P P

CROSS CONNECTION P P P P

AREA ALARMS P P P P

PATIENT OUTLETS P P P P

PARTICLE ANALYSIS P P

PURITY ANALYSIS P P

MGI MEDICAL GAS VERIFIER: BRAYDEN SEGER

SIGNATURE:

DATE: 9/29/2025

MEDICAL GAS ANNUAL TESTING ANALYSIS

MEDICAL GAS TYPE

SCOPE OF

TESTING/VERIFICATION

NFPA 99 2024 Compliant Medical Gas Annual Inspection for a Category 1 Medical Facility. Includes testing of all medical gas source equipment, medical gas zone valves, medical gas master alarm panels, medical gas area alarm panels, medical gas control panels, medical gas flexible terminals and medical gas terminals and medical gas labeling.

ADDITIONAL COMMENTS

https://qrplanet.com/8lq61w

EXECUTIVE SUMMARY

SIGNALS

PASSED

SIGNALS

FAILED

TOTALS 2 30 30 0

MASTER ALARM PANEL TRI-TECH MED TOUCH 1 15 15 0

MASTER ALARM PANEL TRI-TECH MED TOUCH 1 15 15

2 2 0

SOURCE EQUIPMENT MASTER ALARMS

EQUIPMENT

EQUIPMENT MAKE &

MODEL

ALARM PANEL

COUNT

ALARM SIGNAL

COUNT

TOTAL 6 4 2

MASTER ALARM PANEL ALARMS

CLAWVACUUM 1 0 1

OXYGEN BULK OXYGEN 1 1 0

MEDICAL AIR SCROLL 1 0 1

EXECUTIVE OVERALL SUMMARY-SOURCE

SOURCE EQUIPMENT

GAS TYPE SOURCE TYPE TOTAL COUNT TOTAL PASSED TOTAL FAILED

OXYGEN GAS X GAS MANIFOLD 1 1 0

FAILED REPAIRED FAILED REPAIRED

TOTAL PERCENTAGE OF

OUTLETS TESTED

100.0%

TOTAL OUTLET

FAILURES

TOTAL OUTLETS

REPAIRED

1 0

TOTAL 48 47 1 0

PERCENTAGE 97.9% 2.1% 0.0%

WAGD 4 4 0 0

VACUUM 14 13 1 0

MEDICAL AIR 13 13 0 0

GAS TYPE TOTAL COUNT TOTAL PASSED TOTAL FAILED TOTAL UNAVAILABLE

OXYGEN 17 17 0 0

EXECUTIVE OVERALL SUMMARY-PIPELINE

ZONE VALVES AREA ALARMS

TOTAL VALVES TOTAL ALARMSTOTAL PASSED TOTAL PASSED

0 0

PATIENT OUTLET TERMINALS

6 6

MISSING VALVES MISSING ALARMS

0 00 0

MGI TECHNICIAN: BRAYDEN SEGER

1 SPECIFIC OUTLET REPAIRED BY REPAIR DATE

BACK BOOM VACUUM PROCEDURE ROOM 2 AMICO - DC - CH LEAKS W/OUT ADAPTER INSERTED

CAPE GIRARDEAU VA HEALTH CARE CENTER

END OF OUTLET ISSUES

OUTLET ISSUES

ROOM OUTLET SPECS ISSUE

CAPE GIRARDEAU VA HEALTH CARE CENTER

CORRECTED

CORRECTED

END OF CORRECTIVE ACTIONS

ISSUE NFPA 99 2024 CODE

MEDICAL AIR SOURCE FRESH AIR INTAKE IS IMPROPERLY LABELED

5.1.11.1.1 Piping shall be labeled by stenciling or

adhesive markers that identify the patient medical gas, the support gas, or the vacuum system.

NOTE: CORRECTIVE ACTIONS ARE COMPONENTS OF THE MEDICAL GAS SYSTEM THAT DO NOT MEET THE NFPA 99 2024 CODE AND SHOULD BE UPGRADED OR REPAIRED TO MEET THE

NFPA 99 2024 CODE.

CORRECTIVE

ACTION

THE MEDICAL AIR INTAKE NEEDS TO BE PROPERLY LABELED IN THE MECHANICAL ROOM AS WELL AS THE ROOFTOP TO DIFFERENTIATE IT FROM

OTHER EXHAUST LINES AND INTAKES.

CORRECTIVE ACTIONS

AREA ISSUE NFPA 99 2024 CODE

VACUUM SOURCE VACUUM EXHAUST IS IMPROPERLY LABELED

5.1.11.1.1 Piping shall be labeled by stenciling or

adhesive markers that identify the patient medical gas, the support gas, or the vacuum system.

CORRECTIVE

ACTION

THE VACUUM EXHAUST LINE NEEDS TO BE PROPERLY LABELED IN THE MECHANICAL ROOM AS WELL AS THE ROOFTOP TO DIFFERENTIATE IT

FROM OTHER EXHAUST LINES AND INTAKES.

AREA

NOTE: THESE ARE COMPONENTS OF THE MEDICAL GAS SYSTEM THAT DO NOT MEET THE 2024 NFPA 99 CODE, HOWEVER THEY ARE PERMITTED TO

REMAIN IN USE UNTIL THE AREA(S) ARE UPGRADED OR RENOVATED DUE TO THE ABOVE NOT AFFECTING PATIENT CARE.

END OF FUTURE CORRECTIONS

FUTURE CORRECTIONS

AREA ISSUE NFPA 99 2024 CODE

NONE AT THIS TIME.

FUTURE

CORRECTION

MEDICAL GAS MASTER

ALARM ANALYSIS

MASTER ALARM CODE REQUIREMENTS

Master alarm panels for medical gas and vacuum systems shall each include the following signals:

(NFPA 99 2024 5.1.9.2.4)

(1) Alarm indication when, or just before, changeover occurs in a medical gas system that is supplied by a manifold or other alternating-type bulk system that has as a part of its normal operation a changeover from one portion of the operating supply to another.

(2) Alarm indication for a bulk cryogenic liquid system when the main supply reaches an average day’s supply, indicating low contents.

(3) Alarm indication when, or just before, the changeover to the reserve supply occurs in a medical gas system that consists of one or more units that continuously supply the piping system while another unit remains as the reserve supply and operates only in the case of an emergency.

(4) Alarm indication for cylinder reserve pressure low when the content of a cylinder reserve header is reduced below one average day’s supply.

(5) For bulk cryogenic liquid systems, an alarm when or at a predetermined set point before the reserve supply contents fall to one day’s average supply, indicating reserve low.

(6) Where a cryogenic liquid storage unit is used as a reserve for a bulk supply system, an alarm indication when the gas pressure available in the reserve unit is below that required for the medical gas system to function.

(7) Alarm indication when the pressure in the main line of each separate medical gas system increases 20 percent or decreases 20 percent from the normal operating pressure.

(8) Alarm indication when the medical–surgical vacuum pressure in the main line of each vacuum system drops.

(9) Alarm indication(s) from the local alarm panel(s) as described in 5.1.9.5.2 to indicate when one or more of the conditions being monitored at a site is in alarm.

(10) Medical air dew point high alarm from each compressor site to indicate when the line pressure dew point is greater than +2°C (+35°F)

(11) WAGD low alarm when the WAGD vacuum level or flow is below effective operating limits.

(12) An instrument air dew point high alarm from each compressor site to indicate when the line pressure dew point is greater than −30°C (−22°F).

(13) Alarm indication if the primary or reserve production stops on a proportioning system.

CAPE GIRARDEAU VA HEALTH CARE CENTER MGI TECHNICIAN: BRAYDEN SEGER

CAPE GIRARDEAU, MO TESTING DATE: 9/29/2025

VISUAL

STATUS

AUDIBLE

STATUS

LABELED

CORRECTLY

COMMENTS

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

ALARM MAKE AND MODEL: PRE / POST NURSE STATION

COMMENTS

(1) One master alarm panel shall be located in the office or work space of the on-site individual responsible for the maintenance of the medical gas and vacuum piping systems.

(2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location).

PASS/FAIL

PASS

MEDICAL VACUUM HIGH TEMP SHUTDOWN PASS

TRI-TECH MED TOUCH LOCATION:

PER NFPA 99 2024 WHERE IS THE MASTER ALARM LOCATED OF THE FOLLOWING LOCATIONS LOCATION

MEDICAL AIR LINE PRESSURE LOW PASS

MEDICAL VACUUM LAG IN USE PASS

MEDICAL VACUUM LINE PRESSURE LOW PASS

MEDICAL AIR HIGH DEW POINT PASS

MEDICAL AIR CO HIGH PASS

MEDICAL AIR LINE PRESSURE HIGH PASS

MASTER ALARM ANALYSIS

MASTER ALARM SIGNALS PASS/FAIL

OXYGEN PRIMARY LIQUID LEVEL LOW PASS

OXYGEN SECONDARY LIQUID SUPPLY IN USE PASS

OXYGEN SECONDARY LIQUID LEVEL LOW PASS

OXYGEN SECONDARY LIQUID LOW HEAD PRESSURE PASS

OXYGEN LINE PRESSURE HIGH PASS

OXYGEN LINE PRESSURE LOW PASS

MEDICAL AIR COMP MAINTENANCE REQUIRED PASS

CAPE GIRARDEAU VA HEALTH CARE CENTER MGI TECHNICIAN: BRAYDEN SEGER

CAPE GIRARDEAU, MO TESTING DATE: 9/29/2025

VISUAL

STATUS

AUDIBLE

STATUS

LABELED

CORRECTLY

COMMENTS

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

P P P

ALARM MAKE AND MODEL: SECURITY

COMMENTS

OXYGEN SECONDARY LIQUID SUPPLY IN USE PASS

MASTER ALARM ANALYSIS

MASTER ALARM SIGNALS PASS/FAIL

OXYGEN PRIMARY LIQUID LEVEL LOW PASS

OXYGEN SECONDARY LIQUID LEVEL LOW PASS

OXYGEN SECONDARY LIQUID LOW HEAD PRESSURE PASS

OXYGEN LINE PRESSURE HIGH PASS

OXYGEN LINE PRESSURE LOW PASS

MEDICAL AIR COMP MAINTENANCE REQUIRED PASS

MEDICAL AIR HIGH DEW POINT PASS

MEDICAL AIR CO HIGH PASS

MEDICAL AIR LINE PRESSURE HIGH PASS

MEDICAL AIR LINE PRESSURE LOW PASS

TRI-TECH MED TOUCH LOCATION:

MEDICAL VACUUM LAG IN USE PASS

MEDICAL VACUUM LINE PRESSURE LOW PASS

MEDICAL VACUUM HIGH TEMP SHUTDOWN PASS

PER NFPA 99 2024 WHERE IS THE MASTER ALARM LOCATED OF THE FOLLOWING LOCATIONS LOCATION

(1) One master alarm panel shall be located in the office or work space of the on-site individual responsible for the maintenance of the medical gas and vacuum piping systems.

(2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location).

PASS/FAIL

PASS

MEDICAL GAS AREA

ALARM ANALYSIS

(2) *Critical Care Areas

(2)*Anesthetizing locations where moderate sedation, deep sedation, or general anesthesia is administered shall have the sensors installed either on the source side of any of the individual room zone valve box assemblies or on the patient or use side of each of the individual zone valve box assemblies.

(5) Visual and audible indication that the communication with an alarm-initiating devices is disconnected.

(6) Labeling of each indicator, indication the condition monitored.

(7) Labeling of each alarm panel for its area of surveillance.

(8) Reinitiating of the audible signal if another alarm condition occurs while the audible alarm is silenced.

(9) Power for master, area alarms, sensors, and switches from the life safety branch of the emergency electrical system as described in Chapter 6.

Area Alarms. Area alarm panels shall be provided to monitor all medical gas, medical–surgical vacuum, and piped WAGD systems supplying the following: (NFPA 99 2024 5.1.9.4)

(1) Anesthetizing locations where moderate sedation, deep sedation, or general anesthesia is administered.

Area alarm panels for medical gas systems shall indicate if the pressure in the lines in the area being monitored increases or decreases by 20 percent from the normal line pressure. (NFPA 99 2024 5.1.9.4.2)

Area alarm panels for medical–surgical vacuum systems shall indicate if the vacuum in the area drops to or below 300 mm (12 in.) gauge HgV. (NFPA 99 2024 5.1.9.4.3)

Alarm sensors for area alarms shall be located as follows: (NFPA 99 2024 5.1.9.4.4)

(1)*Critical care areas shall have the alarm sensors installed on the patient or use side of each individual zone valve box assemblies.

AREA ALARM CODE REQUIREMENTS

(1) Separate visual indicators for each condition monitored, except as permitted in 5.1.9.5.2 for local alarms that are displayed on master alarm panels.

(2) Visual indicators that remain in alarm until the situation that has caused the alarm is resolved.

(3) Cancelable audible indication of each alarm condition that produces a sound with a minimum level of

80 dBA at 0.92m (3 ft)

(4) Means to visually indicate a lamp or LED failure

Area alarm systems used for medical gas and vacuum systems shall include the following:

(NFPA 99 2024 5.1.9.1)

GAS MONITORED

PRESSURE

READING

LABELING

CORRECT

HIGH

ALARM

SETPOINT

LOW ALARM

SETPOINT

VISUAL

ALARM

FUNCTION

AUDIBLE

ALARM

FUNCTION

MAINLINE

OR ZONE

SENSOR

PASS FAIL

OXYGEN 55 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

MED AIR 52 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

VACUUM 24" HG PASS N/A 12" HG PASS PASS ZONE P

FLOOR: 1ST ALARM LOCATION:

GAS MONITORED

PRESSURE

READING

LABELING

CORRECT

HIGH

ALARM

SETPOINT

LOW ALARM

SETPOINT

VISUAL

ALARM

FUNCTION

AUDIBLE

ALARM

FUNCTION

MAINLINE

OR ZONE

SENSOR

PASS FAIL

OXYGEN 53 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

MED AIR 52 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

VACUUM 23" HG PASS N/A 12" HG PASS PASS ZONE P

FLOOR: 1ST ALARM LOCATION:

GAS MONITORED

PRESSURE

READING

LABELING

CORRECT

HIGH

ALARM

SETPOINT

LOW ALARM

SETPOINT

VISUAL

ALARM

FUNCTION

AUDIBLE

ALARM

FUNCTION

MAINLINE

OR ZONE

SENSOR

PASS FAIL

OXYGEN 53 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

MED AIR 51 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

VACUUM 24" HG PASS N/A 12" HG PASS PASS ZONE P

FLOOR: 1ST ALARM LOCATION:

GAS MONITORED

PRESSURE

READING

LABELING

CORRECT

HIGH

ALARM

SETPOINT

LOW ALARM

SETPOINT

VISUAL

ALARM

FUNCTION

AUDIBLE

ALARM

FUNCTION

MAINLINE

OR ZONE

SENSOR

PASS FAIL

OXYGEN 54 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

MED AIR 52 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

VACUUM 24" HG PASS N/A 12" HG PASS PASS ZONE P

FLOOR: 1ST ALARM LOCATION:

GAS MONITORED

PRESSURE

READING

LABELING

CORRECT

HIGH

ALARM

SETPOINT

LOW ALARM

SETPOINT

VISUAL

ALARM

FUNCTION

AUDIBLE

ALARM

FUNCTION

MAINLINE

OR ZONE

SENSOR

PASS FAIL

OXYGEN 53 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

MED AIR 52 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

VACUUM 24" HG PASS N/A 12" HG PASS PASS ZONE P

FLOOR: 1ST ALARM LOCATION:

GAS MONITORED

PRESSURE

READING

LABELING

CORRECT

HIGH

ALARM

SETPOINT

LOW ALARM

SETPOINT

VISUAL

ALARM

FUNCTION

AUDIBLE

ALARM

FUNCTION

MAINLINE

OR ZONE

SENSOR

PASS FAIL

OXYGEN 53 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

MED AIR 53 PSI PASS 60 PSI 40 PSI PASS PASS ZONE P

VACUUM 24" HG PASS N/A 12" HG PASS PASS ZONE P

FLOOR: 1ST ALARM LOCATION:

END OF 1ST FLOOR AREA ALARM ANALYSIS

AREA ALARM ANALYSIS

1ST FLOOR

AREA MONITORED: COMMENTS

CT SCAN

PROCEDURE ROOM 1 (2011)

OUTSIDE OF CT SCAN ALARM MAKE AND MODEL: BEACON MEDAES MEGA 3

AREA MONITORED: COMMENTS

PRE-OP / PACU

AREA MONITORED: COMMENTS

PRE-OP / PACU NURSE STATION ALARM MAKE AND MODEL: BEACON MEDAES MEGA 3

AREA MONITORED: COMMENTS

ENDOSCOPY 2 (2027)

OUTSIDE OF PROCEDURE 1 ALARM MAKE AND MODEL: BEACON MEDAES MEGA 3

AREA MONITORED: COMMENTS

AREA MONITORED: COMMENTS

OUTSIDE OF ENDOSCOPY 1 ALARM MAKE AND MODEL: BEACON MEDAES MEGA 3

ENDOSCOPY 1 (2025)

PROCEDURE ROOM 2 (2013)

OUTSIDE OF PROCEDURE 2 ALARM MAKE AND MODEL: BEACON MEDAES MEGA 3

OUTSIDE OF ENDOSCOPY 2 ALARM MAKE AND MODEL: BEACON MEDAES MEGA 3

MEDICAL GAS

ZONE VALVE ANALYSIS

Zone valves shall be labeled in accordance with 5.1.11.2. (NFPA 99 2024 5.1.4.1.3)

Zone valves shall be so arranged that shutting off the supply of medical gas or vacuum to one zone will not affect the supply of medical gas or vacuum to another zone or the rest of the system.

(NFPA 99 2024 5.1.4.6.3)

A pressure/vacuum indicator shall be provided on the station outlet/inlet side of each zone valve.

(NFPA 99 2024 5.1.4.6.4)

Zone valve boxes shall not be installed behind normally open or normally closed doors or otherwise hidden from plain view. (NFPA 99 2024 5.1.4.6.1)

Zone valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. (NFPA 99 2024 5.1.4.6.3)

Zone valve boxes shall be installed where they are visible and accessible at all times.

(NFPA 99 2024 5.1.4.6.1 )

Zone valve boxes shall not be located in closed or locked rooms, areas, or closets.

(NFPA 99 2024 5.1.4.6.1)

Zone valves shall be readily operable from a standing position in the corridor on the same floor they serve. (NFPA 99 2024 5.1.4.6.1)

ZONE VALVE CODE REQUIREMENTS

Zone Valves. All station outlets/inlets shall be supplied through a zone valve as follows:

(NFPA 99 2024 5.1.4.6.1)

(2) The zone valves shall serve only outlets/inlets located on that same story.

(3) The zone valve shall not be located in a room with station outlets/inlets that it controls.

(1) The zone valve shall be placed such that a wall intervenes between the valve and outlets/inlets that it controls.

GAS

GAUGE

READING

GAS LABELED

CORRECTLY

ZONE LABELED

CORRECTLY

VALVE SIZE &

TYPE

PROPER

LOCATION

LEAKAGE PASS FAIL

OXYGEN 54 PSI PASS PASS 1" BALL PASS PASS P

MED AIR 52 PSI PASS PASS 1" BALL PASS PASS P

VACUUM 24" HG PASS PASS 1-1/4" BALL PASS PASS P

FLOOR: 1ST VALVE LOCATION:

GAS

GAUGE

READING

GAS LABELED

CORRECTLY

ZONE LABELED

CORRECTLY

VALVE SIZE &

TYPE

PROPER

LOCATION

LEAKAGE PASS FAIL

OXYGEN 53 PSI PASS PASS 3/4" BALL PASS PASS P

MED AIR 52 PSI PASS PASS 3/4" BALL PASS PASS P

VACUUM 24" HG PASS PASS 1-1/4" BALL PASS PASS P

FLOOR: 1ST VALVE LOCATION:

GAS

GAUGE

READING

GAS LABELED

CORRECTLY

ZONE LABELED

CORRECTLY

VALVE SIZE &

TYPE

PROPER

LOCATION

LEAKAGE PASS FAIL

OXYGEN 53 PSI PASS PASS 3/4" BALL PASS PASS P

MED AIR 54 PSI PASS PASS 3/4" BALL PASS PASS P

VACUUM 24" HG PASS PASS 1-1/4" BALL PASS PASS P

FLOOR: 1ST VALVE LOCATION:

GAS

GAUGE

READING

GAS LABELED

CORRECTLY

ZONE LABELED

CORRECTLY

VALVE SIZE &

TYPE

PROPER

LOCATION

LEAKAGE PASS FAIL

OXYGEN 54 PSI PASS PASS 3/4" BALL PASS PASS P

MED AIR 51 PSI PASS PASS 3/4" BALL PASS PASS P

VACUUM 24" HG PASS PASS 1-1/4" BALL PASS PASS P

FLOOR: 1ST VALVE LOCATION:

GAS

GAUGE

READING

GAS LABELED

CORRECTLY

ZONE LABELED

CORRECTLY

VALVE SIZE &

TYPE

PROPER

LOCATION

LEAKAGE PASS FAIL

OXYGEN 54 PSI PASS PASS 3/4" BALL PASS PASS P

MED AIR 53 PSI PASS PASS 3/4" BALL PASS PASS P

VACUUM 24" HG PASS PASS 1-1/4" BALL PASS PASS P

FLOOR: 1ST VALVE LOCATION:

GAS

GAUGE

READING

GAS LABELED

CORRECTLY

ZONE LABELED

CORRECTLY

VALVE SIZE &

TYPE

PROPER

LOCATION

LEAKAGE PASS FAIL

OXYGEN 52 PSI PASS PASS 3/4" BALL PASS PASS P

MED AIR 53 PSI PASS PASS 3/4" BALL PASS PASS P

VACUUM 24" HG PASS PASS 1-1/4" BALL PASS PASS P

FLOOR: 1ST VALVE LOCATION: OUTSIDE OF ENDOSCOPY 2 VALVE MANUFACTURER: BEACON MEDAES

OUTSIDE OF ENDOSCOPY 1 VALVE MANUFACTURER: BEACON MEDAES

COMMENTS

ZONE VALVE ANALYSIS

1ST FLOOR

AREA SERVED: COMMENTS

CT SCAN

PROCEDURE ROOM 1 (2011)

OUTSIDE OF CT SCAN VALVE MANUFACTURER: BEACON MEDAES

AREA SERVED: COMMENTS

PRE-OP / PACU

INSIDE ENDO SUITE VALVE MANUFACTURER: BEACON MEDAES

AREA SERVED: COMMENTS

END OF 1ST FLOOR ZONE VALVE ANALYSIS

OUTSIDE OF PROCEDURE 1 VALVE MANUFACTURER: BEACON MEDAES

AREA SERVED: COMMENTS

PROCEDURE ROOM 2 (2013)

OUTSIDE OF PROCEDURE 2 VALVE MANUFACTURER: BEACON MEDAES

AREA SERVED: COMMENTS

ENDOSCOPY 1 (2025)

ENDOSCOPY 2 (2027)

AREA SERVED:

OUTLET ANALYSIS

OTHER GASES 3.5 SCFM

As specified by ±1%, unless otherwise specified

VACUUM 3.0 SCFM N/A

WAGD 3.0 SCFM N/A

NITROUS OXIDE 3.5 SCFM ≥99% nitrous oxide

NITROGEN 5.0 SCFM ≤1% O2 or ≥99% N2

OXYGEN Non-critical 3.5 SCFM Critical 6.0 SCFM ≥99% oxygen

MEDICAL AIR Non-critical 3.5 SCFM Critical 6.0 SCFM 19.5%–23.5% oxygen

Support gas outlets shall deliver 140 SLPM (5.0 SCFM) with a pressure drop of not more than 35 kPa

(5 psi) gauge and static pressure of 1100 kPa to 1275 kPa (160 psi to 185 psi) gauge.

(NFPA 99 2024 5.1.12.4.10.3)

Medical–surgical vacuum inlets shall draw 85 Nl/min (3 SCFM) without reducing the vacuum pressure below 300 mm (12 in.) gauge HgV at any adjacent station inlet. (NFPA 99 2024 5.1.12.4.10.4)

Oxygen and medical air outlets serving critical care areas shall allow a transient flow rate of 170 SLPM

(6 SCFM) for 3 seconds. (NFPA 99 2024 5.1.12.4.10.5)

Medical gas concentration & flow rate requirements. (NFPA 99 2024 Table 5.1.12.4.11)

GAS FLOW RATE CONCENTRATION

OUTLET CODE REQUIREMENTS

Each station outlet/inlet for medical gases or vacuums shall be gas-specific, whether the outlet/inlet is threaded or is a noninterchangeable quick coupler. (NFPA 99 2024 5.1.5.1)

Each outlet/inlet shall be legibly identified in accordance with 5.1.11.3.1. (NFPA 99 2024 5.1.11.3)

Each station outlet/inlet, including those mounted in columns, hose reels, ceiling tracks, or other special installations, shall be designed so that parts or components that are required to be gas specific for compliance with 5.1.5.1 and 5.1.5.9 cannot be interchanged between the station outlet/inlet for different gases. (NFPA 99 2024 5.1.5.7)

All gas outlets with a gauge pressure of 345 kPa (50 psi), including, but not limited to, oxygen, nitrous oxide, medical air, and carbon dioxide, shall deliver 100 SLPM (3.5 SCFM) with a pressure drop of not more than 35 kPa (5 psi) and static pressure of 345 kPa to 380 kPa (50 psi to 55 psi).

(NFPA 99 2024 5.1.12.4.10.2)

OUTLET LOCATION

Le ak ag e w

A d ap te r Le ak ag e w

/o

A d ap te r O p e ra ti o n al

Fl o w

St at ic P re ss u re

C o n ce n tr at io n

C o n d it io n

La b e lin g

PASS FAIL REPAIRED

1ST FLOOR OXY MED AIR

MED

VAC

WAGD

CT SCAN 1 1 1 BEACON 500 CH P P P P P P P

PROCEDURE ROOM 1 2 1 2 1 AMICO DC CH P P P P P P P

PROCEDURE ROOM 2 2 1 2 1 AMICO DC CH P P P P P

ENDOSCOPY 1 2 1 2 1 AMICO DC CH P P P P P P P

ENDOSCOPY 2 2 1 2 1 AMICO DC CH P P P P P P P

PRE-OP / PACU BAY 1 2 2 2 AMICO SB CH P P P P P P P

PRE-OP / PACU BAY 2 2 2 2 AMICO SB CH P P P P P P P

PRE-OP / PACU BAY 3 2 2 2 AMICO SB CH P P P P P P P

PRE-OP / PACU BAY 4 2 2 2 AMICO SB CH P P P P P P P

TOTAL COUNT: 17 13 17 4

OUTLET ANALYSIS

GAS TYPE & OUTLET QUANTITY OUTLET SPECS COMMENTS

BACK BOOM VAC LEAKS W/O

ADAPTER

OUTLET PURITY &

CROSS CONNECT

ANALYSIS

2) Purity verification at 10 percent of the existing outlets annually.

OUTLET PURITY & CROSS CONNECT REQUIREMENTS

VHA DIRECTIVE 7515

1.REASON FOR ISSUE: This Veterans Health Administration (VHA) directiveestablishes policy for the

Department of Veterans Affairs (VA) regarding the safeinstallation, operation, and maintenance of

Medical Gas and Vacuum Systems at VAmedical facilities.

VHA DIRECTIVE 7515(1) A-1 APPENDIX A

(1) Cross connection verification of 10 percent of the existing outlets annually. Testing cannot be repeated on an outlet until all outlets in the hospital have been tested once. Additionally, testing of newly installed outlets must not supersede the testing of existing outlets.

OUTLET LOCATION

O2

AIR

COMMENTS

OUTLETS TESTED OXY MED AIR

MED

VAC

CT SCAN 1 1 1 99.9% 21.0%

ENDO ROOM 1 2 1 1 99.9% 21.0%

PROCEDURE ROOM 2 2 1 2 99.9% 21.0%

PRE-OP 2 2 2 2 99.9% 21.0%

PRE-OP 4 2 2 2 99.9% 21.0%

TOTAL COUNT: 9 7 8

INDIVIDUAL

PRESSURIZATION

PASS PASS

INDIVIDUAL

PRESSURIZATION

PASS PASS

INDIVIDUAL

PRESSURIZATION

PASS PASS

INDIVIDUAL

PRESSURIZATION

PASS PASS

INDIVIDUAL

PRESSURIZATION

PASS PASS

OUTLET CROSS-CONNECT &

PURITY TESTING

GAS TYPE & OUTLET

QUANTITY

CROSS-CONNECT

PROCEDURE

PURITY

ANALYSIS

CROSS

CONNECT

PASS/FAIL

CSMEDGAS.COM COMPLIANCE SOLUTIONS 1-833-5MEDGAS

MEDICAL GAS SOURCE

EQUIPMENT ANALYSIS

LOCATION BULK PAD

AREA(S) OF FACILITY SERVED ENTIRE FACILITY

BULK SUPPLIER TAYLOR WHARTON

SYSTEM TYPE LIQUID X HP IN-BUILDING RESERVE

PRIMARY LIQUID LEVEL 72"

PRIMARY PRESSURE 51 PSI

RESERVE LIQUID LEVEL N/A

RESERVE PRESSURE 1950 PSI

PRIMARY FINAL LINE PRESSURE 53 PSI

RESERVE FINAL LINE PRESSURE 53 PSI

SOURCE VALVE PRESSURE 52 PSI

MAIN VALVE PRESSURE 52 PSI

SOURCE VALVE TYPE BALL VALVE

SOURCE VALVE LOCATION AT SOURCE

PRESSURE SWITCH LOCATION INSIDE SOILED UTILITY ROOM BY EOSC

EOSC VALVE SIZE 2"

EOSC LOCATION(S) OUTSIDE OF MANIFOLD ROOM

PASS FAIL N/A

P

P

P

P

P

P

P

P

P

P

P

P

P

P

Proper fill circuit (inlet, strainer, check valve, purge valve, supports)

BULK OXYGEN

SOURCE EVALUATION DATA

NFPA 99 2024 SCHEMATIC

NFPA 99 2024 CHECKLIST

System visibly complies with above schematic per NFPA 99.

Enclosure (min 6' height) non-combustible, proper ventilation & 2 lockable entries/exits

Containers permanently anchored & cylinders adequately secured

Noncombustible pad w/3' maintenance clearance, accessible for delivery & pad adequately sized for vehicles

Top & bottom fill, hose purge, & vent valves present

Piped w/brazed copper, brass, or stainless & no flex connects/fittings wear & leaks

Reserve and primary check valves in place for reserve to feed automatically

Reserve economizer in place to feed upstream final regulators

Drainage prevented towards (buildings, drains, etc.) & from hazards

Labeling: pipeline, source/main valves & "Oxygen-No Smoking, No Open Flames"

Vaporizer appears adequately sized & isolation valves arranged for service w/o supply interruption

Emergency Supply (3' clearance) or (IBER) w/2 checks, secured, & labeled

Distance from the following: 1' - all structures (Type I & II), * 50' - wood framed Type III, IV, or V building types, * 50' - Public assembly or nearest non- ambulatory patient, * 5' -

Property lines & overhead electrical wiring, 10' building openings, * 10' - public sidewalks & parked vehicles, * 15' - Hazardous piping materials & below ground flammable liquid tanks, * 25' - 0-1000 gal flammable liquids/liquefied gas, below ground flammable liquid fill or vent, 0-25,000 scf flammable gases, or slow burning solids, * 50' - >1000 gal flammable liquids/liquefied gas, >25,000 scf flammable gases, or rapidly burning solids, 3' - combustible surfaces (asphalt & expansion joint filler) where liquid oxygen may fall, 8' - Sewer or drain openings to delivery connects, reliefs, mobile supply equipment, & liquid withdrawal connects, Walls may not form a 3-4 sided court.

MEETS ALL NFPA 99 2024 CODE REQUIREMENTS PASS

ADDITIONAL COMMENTS

LOCATION MANIFOLD ROOM

AREA(S) OF FACILITY SERVED EMERGENCY RESERVE FOR ENTIRE FACILITY

MANUFACTURER BEACON MEDAES

MODEL NUMBER 4107213324

SERIAL NUMBER HOP811925

SYSTEM TYPE HIGH PRESSURE X HIGH PRESSURE

CYLINDERS ON RIGHT BANK 4

CYLINDERS ON LEFT BANK 4

RIGHT BANK PRESSURE 1800 PSI

LEFT BANK PRESSURE 1800 PSI

CHANGE OVER PRESSURE 200 PSI

LINE PRESSURE 53 PSI

SOURCE VALVE TYPE BALL VALVE

SOURCE VALVE LOCATION ABOVE MANIFOLD

PRESSURE SWITCH LOCATION SOILED UTILITY ROOM BY LOADING DOCK

PASS FAIL N/A

P

P

P

P

N/A

P

P

P

P

P

P

P

P

P

P

P

ADDITIONAL COMMENTS

Cylinders secured with racks or chains

Headers have header valve and check valves

Cylinders prevented from reaching temperatures in excess 130°F. and lower than 20°F.

Door Labeling: CAUTION, Medical Gases, No Smoking or Open Flame, Room May Have Insufficient Oxygen Open Door & Allow Room to Ventilate before

Entering

MEETS ALL NFPA 99 2024 CODE REQUIREMENTS PASS

Electrical devices protected in room

System visibly complies with above schematic per NFPA 99.

Secured with lockable doors or gates or otherwise secured.

1 hour fire rated door and walls.

Source valve labeled per NFPA 99.

Proper natural ventilation

Proper mechanical ventilation

Manifold power supplied from emergency power

Automatic bank alternation

Warning lights when banks alternate

Relief Valves vented outside, pipe size, turned down, & screened

No flammable materials, cylinders containing flammable gases, or containers containing flammable liquids

NFPA 99 2024 CHECKLIST

OXYGEN MANIFOLD SYSTEM

SOURCE EVALUATION DATA

NFPA 99 2024 SCHEMATIC

LOCATION MECHANICAL ROOM LINE PRESSURE

AREA(S) OF FACILITY SERVED ENTIRE FACILITY DRYER TYPE

MANUFACTURER POWEREX DRYER INFO

MODEL NUMBER STD0502S0025952 DEW POINT MONITOR INFO

SERIAL NUMBER (M)6/18/2021-S25952-5241 CO MONITOR INFO

SYSTEM TYPE SCROLL SOURCE VALVE LOCATION

CONFIGURATION DUPLEX PRESSURE SWITCH LOCATION

PUMP MAKE AND MODEL POWEREX SL016502AV PUMP 1 HOURS

HORSEPOWER 5 H.P. PUMP 2 HOURS

LEAD ON/OFF 80 PSI / 110 PSI PUMP 3 HOURS

LAG ON/OFF 95 PSI / 105 PSI PUMP 4 HOURS

ELEMENT NFPA LIMIT READING PASS/FAIL

DEW POINT (MONITOR ON SYSTEM) NEG 22 DEG F NEG 76 DEG F

DEW POINT (CS MONITOR) NEG 22 DEG F NEG 55 DEG F

CARBON MONOXIDE (MONITOR ON SYSTEM) N/A

CARBON MONOXIDE (CS MONITOR) N/A

OXYGEN N/A

PASS FAIL N/A

P

P

P

P

P

P

P

P

P

P

P

P

P

P

P

P

MEETS ALL NFPA 99 2024 CODE REQUIREMENTS PASS

ADDITIONAL COMMENTS

System automatically alternates the pumps evenly

Duplexed dryer system

1/4" sample port installed

Source valve in proper location and labeled

Mainline and intake piping properly labeled

Each pump has an isolation valve so a pump can be serviced without interruption of the system

NFPA 99 2024 CHECKLIST

System visibly complies with above schematic per NFPA 99.

Indoors in a dedicated mechanical equipment area, adequately ventilated and with any required utilities

System has two or more instrument air compressors or a standby header

System is supplied with flexible connectors on inlet and outlet sides of the compressors

System power supplied from emergency power

System is equipped with manual disconnects

System is equipped with a local lag and dew point alarm

The local alarms are wired to the master alarm panel

Receiver tank is supplied with an Auto drain, pressure gauge, sight glass, pressure relief, & ASME label

There is a receiver bypass valve so the receiver can be serviced without interruption of the system

N/A

NFPA 99 2024 SCHEMATIC COMPRESSED AIR PURITY ANALYSIS

COMMENTS

N/A

COMPRESSED AIR SYSTEM

SOURCE EVALUATION DATA

55 PSI

DESICCANT

TRIDENT DRYSPELL

PDPM 100

N/A

AT SOURCE

N/A

LOCATION MECHANICAL ROOM LINE PRESSURE

AREA(S) OF FACILITY SERVED ENTIRE FACILITY DRYER TYPE

MANUFACTURER POWEREX DRYER INFO

MODEL NUMBER MSD03A34K DEW POINT MONITOR INFO

SERIAL NUMBER (H)6/12/2021-S25952-3172 CO MONITOR INFO

SYSTEM TYPE SCROLL SOURCE VALVE LOCATION

CONFIGURATION DUPLEX PRESSURE SWITCH LOCATION

PUMP MAKE AND MODEL POWEREX SL014003AV PUMP 1 HOURS

HORSEPOWER 3 HP PUMP 2 HOURS

LEAD ON/OFF 105 / 95 PSI PUMP 3 HOURS

LAG ON/OFF 95 / 85 PSI PUMP 4 HOURS

ELEMENT NFPA LIMIT READING PASS/FAIL

DEW POINT (MONITOR ON SYSTEM) 35 DEG F -28 DEG F PASS

DEW POINT (CS MONITOR) 35 DEG F -32 DEG F PASS

CARBON MONOXIDE (MONITOR ON SYSTEM) 10 PPM 0 PPM PASS

CARBON MONOXIDE (CS MONITOR) 10 PPM 0 PPM PASS

CARBON DIOXIDE 500 PPM 97 PPM PASS

METHANE 25 PPM 0 PPM PASS

CHLOROFORM 2 PPM 0 PPM PASS

OXYGEN 19.5%-23.5% 21.2% PASS

PASS FAIL N/A

P

P

P

P

P

P

P

P

P

P

P

P

P

P

PIntake turned down and screened

MEETS ALL NFPA 99 2024 CODE REQUIREMENTS FAIL

ADDITIONAL COMMENTS

FRESH AIR INTAKE LINE IS IMPROPERLY LABELED AS MEDICAL AIR MAINLINE.

Intake above roof level, >20' above ground, 10 ft from doors, windows, other openings, and 25' from exhausts

System is equipped with manual disconnects

System is equipped with a local lag, dew point and CO alarm

The local alarms are wired to the master alarm panel

Receiver tank is supplied with an Auto drain, pressure gauge, sight glass, pressure relief, & ASME label

There is a receiver bypass valve so the receiver can be serviced without interruption of the system

Each pump has an isolation valve so a pump can be serviced without interruption of the system

System automatically alternates the pumps evenly

Duplexed dryer system

1/4" sample port installed

Source valve in proper location and labeled

Mainline and intake piping properly labeled

System power supplied from emergency power

N/A

NFPA 99 2024 SCHEMATIC MEDICAL AIR PURITY ANALYSIS

COMMENTS

NFPA 99 2024 CHECKLIST

System visibly complies with above schematic per NFPA 99.

Indoors in a dedicated mechanical equipment area, adequately ventilated and with any required utilities

System has two or more medical air compressors

System is supplied with flexible connectors on inlet and outlet sides of the compressors

N/A

MEDICAL AIR SYSTEM

SOURCE EVALUATION DATA

100 PSI

DESICCANT

TRIDENT DRYSPELL +

POWEREX PDPM1001AJ

ENMET CO-GUARD

ABOVE SOURCE

ABOVE SOURCE

LOCATION MECHANICAL ROOM

AREA(S) OF FACILITY SERVED ENTIRE FACILITY

MANUFACTURER POWEREX

MODEL NUMBER CVTD0303V4K1HT

SERIAL NUMBER (H)5/27/2021-S000025952-3130

SYSTEM TYPE CLAW

CONFIGURATION DUPLEX

PUMP MAKE AND MODEL BUSCH MM1144.BVZ6.BAXX

HORSEPOWER 3 HP

LEAD ON/OFF 22/18" HG

LAG ON/OFF 19/16" HG

LINE PRESSURE 25" HG

SOURCE VALVE LOCATION AT SOURCE

PRESSURE SWITCH LOCATION AT SOURCE

PUMP 1 HOURS 13449

PUMP 2 HOURS 11083

PUMP 3 HOURS N/A

PUMP 4 HOURS N/A

PASS FAIL N/A

P

P

P

P

P

P

P

P

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P

P

FAIL

ADDITIONAL COMMENTS

EXHAUST IS IMPROPERLY LABELED AS AN AIR INTAKE AND NOT VACUUM EXHAUST.

System automatically alternates the pumps evenly

Source valve in proper location and labeled

Mainline and exhaust piping properly labeled

Exhaust is turned down and screened

Exhaust ≥25' from doors, windows, intakes, building openings & public assembly & copper or stainless, no dips, drip legs installed, & sufficient diameter

MEETS ALL NFPA 99 2024 CODE REQUIREMENTS

Each pump has an isolation valve so a pump can be serviced without interruption of the system

System visibly complies with above schematic per NFPA 99.

Located in a dedicated mechanical equipment area, adequately ventilated and with any required utilities

System has two or more medical vacuum pumps

System has flexible connectors

System has antivibration mountings

System power supplied from emergency power

System is equipped with manual disconnects

System is equipped with a local lag alarm

The local alarms are wired to the master alarm panel

Receiver tank is supplied with an Auto drain & ASME label

There is a receiver bypass valve so the receiver can be serviced without interruption of the system

NFPA 99 2024 CHECKLIST

MEDICAL VACUUM SYSTEM

SOURCE EVALUATION DATA

NFPA 99 2024 SCHEMATIC

END OF REPORT

"Your Med Gas Experts"

CAPE GIRARDEAU VA HEALTH CARE CENTER

711 S MT AUBURN RD

CAPE GIRARDEAU, MO