A0002_Attachment B - Inspection Reports.pdf

RECOMMENDATIONS

Health Choice Enterprises, LLC

4350 Brownsboro Rd. Suite 133

Louisville, KY 40207

800-957-4758

Eugene J. Towbin VA Healthcare Center April 3rd, 2024

ITEM LOCATION PROBLEM / DEFICIENCY RECOMMENDATION CORRECTION

ADVISED REFERENCE DEFICIENCY

CORRECTED

MS 1

Vacuum Low Level Master Alarm Switch

The vacuum switch is not on the line via a DISS fitting connection to allow for service.

Install the required fitting. Yes

NFPA 99 2021

5.1.8.2.3

All pressure-sensing devices and main line pressure gauges downstream of the source valves shall be provided with a gas-specific demand check fitting to facilitate service testing or replacement.

MS 2

Master Alarm Panels & Medical

Air Source Equipment

HCE was unable to test the "Lag Compressor In Use" alarm on this industrial Medical Air Compressor

System.

We advise that the facility have the company that is performing the Periodic

Mainanace on this system to test the "Lag Compressor In Use" alarm and have them document the results for the facility.

Yes

NFPA 99 2021

5.1.9.2 Master Alarms

(Reference Table A.5.1.9.2)

MS 3 Both Master Alarm Panels

Alarm Missing… Med Air Line High

Troubleshoot the problem and make the necessary repair to the wiring and/or the switches.

Yes

NFPA 99 2021

5.1.9.2.4

(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

SOURCE EQUIPMENT & MASTER ALARM PANELS

ITEM LOCATION PROBLEM / DEFICIENCY RECOMMENDATION CORRECTION

ADVISED REFERENCE DEFICIENCY

CORRECTED

No recommendations for the Zone Valves or Area

Alarms at the time of this annual.

ZONE VALVES & AREA ALARM PANELS

FUTURE COMPONENT

UPGRADE LIST

(FOR REFERENCE ONLY,

NOT RECOMMENDATIONS)

NOTE: THESE ARE COMPONENTS OF THE SYSTEM

WHICH ARE NOT CURRENT EDITION NFPA 99

COMPLIANT, HOWEVER THEY ARE PERMITTED

TO REMAIN IN USE UNTIL THE AREA(S) ARE

UPGRADED OR RENOVATED.

ITEM LOCATION PROBLEM / DEFICIENCY RECOMMENDATION CORRECTION

ADVISED REFERENCE DEFICIENCY

CORRECTED

OS 1

Emergency Oxygen

Secondary Connetion

(EOSC)

There is no relief vent line for the EOSC connection.

Install the required relief vent line during the next Oxygen system shutdown Not at this time.

NFPA 99 2021

5.1.3.5.13.2

EOSCs shall consist of the following:

(5) Relief valve sized to protect the downstream piping system and related equipment from exposure to pressures in excess of 50 percent higher than normal line pressure

OS 2

Emergency Oxygen

Secondary Connetion

(EOSC)

The check vlave just downstream of this EOSC is not holding pressure.

Install a replament check valve during the next Oxygen system shutdown.

Not at this time. NFPA 99 2021 & General

Maintenance

OS 3 Medical Vacuum System

There is no dedicated Source Valve that meets the NFPA 99

2021 code.

A new valve would need to be installed.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.4.2 Source Valve

5.1.4.2.1 A shutoff valve shall

be placed at the immediate connection of each central supply system to the piped distribution system to allow the entire central supply system, including all accessory devices (e.g., air dryers, final line regulators), to be isolated from the facility.

Eugene J. Towbin VA Healthcare Center April 3rd, 2024

OBSERVATIONS FOR FUTURE UPGRADES - NOT RECOMMENDATIONS

CORRECTED

OS 4 Vacuum Exhaust Vent Line.

The Exhaust discharge is not 25 ft from building openings.

Also, not turned down and screened.

The Vacuum Exhaust would have to relocated or the pipe extended for the discharge point.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.3.7.7.2 The exhaust shall

be located as follows:

(2) At least 7.5 m (25 ft) from any door, window, air intake, or other openings in buildings or places of public assembly.

5.1.3.7.7.3 The end of the exhaust shall be turned down and screened or otherwise be protected against the entry of vermin, debris, or precipitation by screening fabricated or composed of a noncorroding material.

Eugene J. Towbin VA Healthcare Center April 3rd, 2024

CORRECTED

OZ 1

Multiple (original to building) zone valves

No gauges are present on patient side of valves

Install valves with gauges if / when these areas are remodeled / upgraded Not at this time

NFPA 99 2021

5.1.4.6.4

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

Eugene J. Towbin VA Healthcare Center April 3rd, 2024

OUTLET ISSUES

4350 Brownsboro Rd. Suite 133

FACILITY Eugene J. Towbin VA Healthcare Ctr DATE TESTED Apr-24

PHONE#

AREA SPECIFIC OUTLET LOCATION DEFICIENCY (SEE CODES BELOW) DATE CORRECTED

1ST FLOOR

NO ISSUES FOUND

OXYGEN #3/4

2ND FLOOR

NO ISSUES FOUND

3RD FLOOR

3E-127

OUTLET CODES:

#1 Adapter will not lock #2 Difficult to insert / remove adapter #3 Leak with adapter inserted #4 Leak without adapter inserted #5 Reduced flow #6 No flow #7 Equipment in use / unable to test #8 Control Panel Leaks #9 No hose present #10 Outlet missing parts #11 Outlet broken / malfunctioning #12 Misc. issue with the outlet

HEALTH CHOICE ENTERPRISES, LLC

OUTLET ISSUES

NOTE: THE OUTLETS LISTED AS LEAKING ARE NOT AFFECTING PATIENT CARE AND ARE NOT CREATING ANY ENVIRONMENTAL HAZARDS. MAINTENANCE IS LEFT

TO THE DISCRETION OF THE FACILITY. REFERENCE NFPA 99 2021

4350 Brownsboro Rd. Suite 133

John L. McClellan Memorial Veterans Hospital April 2nd - 5th, 2024

ITEM LOCATION PROBLEM / DEFICIENCY RECOMMENDATION CORRECTION

ADVISED REFERENCE DEFICIENCY

CORRECTED

MS 1

Bulk Oxygen Local Alarm

Panel

None of the audible alarms work on the Local Alarm panel monitoring the Bulk

Oxygen Signals.

Troubleshoot the problem and make the necessary repair to the Local Alarm Panel.

Yes

NFPA 99 2021

5.1.9.1 General.

All master, area, and local alarm systems used for medical gas and vacuum systems shall include the following:

(3) Cancelable audible indication of each alarm condition that produces a sound with a minimum level of 80 dBA at 0.92 m (3 ft)

MS 2

Master Alarm Panels

(Boiler Room Office)

Alarm Missing…

1) Med Air Line High

Alarms Not working….

1) Vacuum Line Pressure

Low

Troubleshoot the problem and make the necessary repair to the wiring and/or the switches.

Yes

NFPA 99 2021

5.1.9.2 Master Alarms

(Reference Table A.5.1.9.2)

MS 3

Master Alarm Panels (Sterile

Processing Department)

Alarm Missing…

1) Med Air Line High

Alarms Not working….

1) Vacuum Line Pressure.

Low

2) Oxygen High Line Pressure

Troubleshoot the problem and make the necessary repair to the wiring and/or the switches.

Yes

NFPA 99 2021

5.1.9.2 Master Alarms

(Reference Table A.5.1.9.2)

MS 4

Master Alarm Panels & Medical

Air Source Equipment

HCE was unable to test the "Lag Compressor In Use" alarm on this industrial Medical Air Compressor

System.

We advise that the facility have the company that is performing the Periodic

Mainanace on this system to test the "Lag Compressor In Use" alarm and have them document the results for the facility.

Yes

NFPA 99 2021

5.1.9.2 Master Alarms

(Reference Table A.5.1.9.2)

ITEM LOCATION PROBLEM / DEFICIENCY RECOMMENDATION CORRECTION

ADVISED REFERENCE DEFICIENCY

CORRECTED

MS 5 C02 Manifold Light switch not protected Install protective covering for light switch Yes

NFPA 99 2021

5.1.3.3.2.1

(13) They shall protect electrical devices from physical damage.

RECOMMENDATIONS

SOURCE EQUIPMENT & MASTER ALARM PANELS

ZR 7

Nitrogen Manifold

Left Bank in Use indicator light no functional

Have light repaired or replaced

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.3.5.10.6

Manifolds shall have a local signal that visibly indicates the operating status

CORRECTED

ZR 1

Radiology X-Ray 1, 2, & 3 (1E: 191, 192, 193)

No Zone Valves could be located that serves these outlets.

Have a zone valve installed to serve these rooms.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.4.6.1

All station outlets/inlets shall be supplied through a zone valve

ZR 2

Urology Waiting (Bays 1, 2, & 3), & Anesthesia Workroom

No Zone Valves could be located that serves these outlets.

Have a zone valve installed to serve these rooms.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.4.6.1

All station outlets/inlets shall be supplied through a zone valve

ZR 3

Zone Valves serving:

Recovery:

Bays 1 - 15, &

Iso Rm 16

Zone Valves are in the same area as the outlets that they serve.

Relocate the zone valve box if the AHJ deems it necessary.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.4.6.1 Zone Valves

All station outlets/inlets shall be supplied through a zone valve, which shall be placed as follows::

(1) It is installed so that a wall intervenes between the valve and the outlets/inlets that it controls.

ZR 4

Area Alarm Panel Monitoring:

Procedure Rm 12 (2B-173)

Required Area Alarm panel for this room is missing.

Have the missing Area Alarm Panel installed per the NFPA

99 2021 requirements.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.9.4* Area Alarms.

Area alarm panels shall be provided to monitor all medical gas, medical–surgical vacuum, and piped WAGD systems supplying the following:

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

(2)* Category 1 spaces

ZR 5 2D Rehab: 143, 145, 146, 148

No Zone Valves could be located that serves these outlets.

Have a zone valve installed to serve these rooms.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.4.6.1

All station outlets/inlets shall be supplied through a zone valve

John L. McClellan Memorial Veterans Hospital April 2nd - 5th, 2024

CORRECTED

ZR 6

Zone Valves serving:

5D-163

(Hemodialysis - Bays 1 thru 11), 5D-166 (Iso Rm

12), 5D-131, 132, 134, 135 (Exam

Rms)

Zone Valves are in the same area as the outlets that they serve.

Relocate the zone valve box if the AHJ deems it necessary.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.4.6.1 Zone Valves

All station outlets/inlets shall be supplied through a zone valve, which shall be placed as follows::

(1) It is installed so that a wall intervenes between the valve and the outlets/inlets that it controls.

John L. McClellan Memorial Veterans Hospital April 2nd - 5th, 2024

FUTURE COMPONENT

UPGRADE LIST

(FOR REFERENCE ONLY,

NOT RECOMMENDATIONS)

NOTE: THESE ARE COMPONENTS OF THE SYSTEM

WHICH ARE NOT CURRENT EDITION NFPA 99

COMPLIANT, HOWEVER THEY ARE PERMITTED

TO REMAIN IN USE UNTIL THE AREA(S) ARE

UPGRADED OR RENOVATED.

CORRECTED

OS 1 Medical Air Intake

The Medical Air FreshAir Intake dpes not appear to meet the current NFPA 99 2021 requirements.

Verify that the code requirements are met.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPS 99 2021 5.1.3.6.3.11

Compressor Intake.

(E) If an air source equal to or better than outside air (e.g., air already filtered for use in operating room ventilating systems) is available, it shall be permitted to be used for the medical air compressors with the following provisions:

(2) Ventilating systems having fans with motors or drive belts located in the airstream shall not be used as a source of medical air intake.

OS 2 Medical Air System

The Lab Air should not be tied in to the Medical Air System.

The Lab Air sould have a system of it's own

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.3.5.2 Permitted Locations

for Medical Gases. Central supply systems for oxygen, medical air, nitrous oxide, carbon dioxide, and all other patient medical gases shall be piped only to medical gas outlets complying with 5.1.5, into areas where the gases will be used under the direction of licensed medical profession

OS 3

Medical Vacuum System

(Main Vac System)

The Lab Vac should not be tied in to the Medical Vacuum

System.

The Lab Vac sould have a system of it's own

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.14.3.4* The medical–surgical vacuum and WAGD systems shall not be used for nonmedical applications.

John L. McClellan Memorial Veterans Hospital April 2nd - 5th, 2024

CORRECTED

OS 4

Medical Vacuum System

(Main Vac System)

There is no dedicated Source Valve that meets the NFPA 99

2021 code.

A new valve would need to be installed or possible relocate the existing Master Alarm Low Vac Switch.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.4.2 Source Valve

5.1.4.2.1 A shutoff valve shall

be placed at the immediate connection of each central supply system to the piped distribution system to allow the entire central supply system, including all accessory devices (e.g., air dryers, final line regulators), to be isolated from the facility.

5.1.9.2.5 The alarm

indications required in 5.1.9.2.4(7) and 5.1.9.2.4(8) shall originate from sensors installed in the main lines immediately downstream (on the patient or use side) of the source valves.

OS 5

Medical Vacuum System

(Main Vac System)

Vacuum Exhaust is of a PVC material. NFPA 99 2021 Code calls for Copper, Stainless- Steel, or CMT to be used.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.10.2.1 Tubes for Vacuum.

Piping for vacuum systems shall be constructed of any of the following:

(1) Hard-drawn seamless copper tube…

(2) Stainless steel tube…

(3) CMT...

John L. McClellan Memorial Veterans Hospital April 2nd - 5th, 2024

CORRECTED

OZ 1

Multiple (original to building) zone valves

No gauges are present on patient side of valves

Install valves with gauges if / when these areas are remodeled / upgraded Not at this time

NFPA 99 2021

5.1.4.6.4

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

OZ 2 GB: Lab Department

The Medical Air and Medical Vacuum are intented only to be used for direct patient care or the calibration of equipment to be used on patients.

Take the Medical Air and Medical Vacuum Out of

Service that is serving this area.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021

5.1.14.3.4* The medical–surgical vacuum and WAGD systems shall not be used for nonmedical applications.

5.1.3.5.2 Permitted Locations

for Medical Gases. Central supply systems for oxygen, medical air, nitrous oxide, carbon dioxide, and all other patient medical gases shall be piped only to medical gas outlets complying with 5.1.5, into areas where the gases will be used under the direction of licensed medical professionals

OZ 3

Oxygen Zone Valve serving:

OR 1

(2B-112)

Oxygen valve leaks in the closed positions.

None at this time. Leak is not affecting patient care.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021 & General Maintenance

OZ 4

Oxygen Zone Valve serving:

PROCEDURE

ROOM 12

(2B-173)

Oxygen valve leaks in the closed positions.

None at this time. Leak is not affecting patient care.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021 & General Maintenance

John L. McClellan Memorial Veterans Hospital April 2nd - 5th, 2024

CORRECTED

OZ 5

Oxygen & Medical Air Zone Valves serving:

4D: Rms 107, 107B, 110, 112, 114, 116, 117, 123, 127, 129, &

Zone Valve handles do not stop at the 90 position.

(Quarter-Turn Ball Valves)

Replace with the proper handles if they are available.

The authority having jurisdiction should decide whether or not these corrections are necessary at this time.

NFPA 99 2021 & General Maintenance

John L. McClellan Memorial Veterans Hospital April 2nd - 5th, 2024

OUTLET ISSUES

4350 Brownsboro Rd. Suite 133

FACILITY Mc Clellan VA Medical Center DATE TESTED 4/2-5/2024 CONTACT Arnold Palmer

PHONE#

AREA SPECIFIC OUTLET LOCATION DEFICIENCY (SEE CODES BELOW) DATE CORRECTED

1ST FLOOR

ER EXAM ROOM 3 OXYGEN #4

CT 3 VACUUM #3

STRESS LAB 158 MED AIR #2/3

2ND FLOOR

PRE-OP BAY 17 VACUUM #4

OR 1 - LEFT CEILING REAR VACUUM #4

OR 2 - RIGHT CEILING FRONT VACUUM #4

OR 4 - FRONT CEILING LEFT FRONT VACUUM #4

OR 4 - REAR CEILING RIGHT FRONT VACUUM #5

OR 5 - FRONT CEILING FRONT VACUUM #4

OR 5 - REAR CEILING REAR VACUUM #1

OR 7 - REAR CEILING FRONT VACUUM #4

OR 8 - RIGHT CEILING FRONT VACUUM #4

OR 13 OXYGEN DISS AT CEILING SUBSTANTIAL LEAK ABOVE CEILING

SICU 3 RIGHT VACUUM #4

SICU 9 MIDDLE VACUUM #4

SICU 11 RIGHT VACUUM #4

4TH FLOOR

4B- 116 OXYGEN #3

4B- 123 RIGHT VACUUM #4

4B- 127 RIGHT VACUUM #4

4B-132 MED AIR #3/4

4B- 147 MED AIR #4

4D- 147 MED AIR LEAK BEHIND WALL

4D- 143 LEFT VACUUM #4

4E- 151 MED AIR #4

5TH FLOOR

5B- 134 RIGHT FRONT VACUUM #6

5B- 134 BACK LEFT VACUUM #2

5B- 136 BACK LEFT VACUUM #2

6TH FLOOR

6D- 116 MED AIR #4

6D- 117 LEFT VACUUM #5

OUTLET CODES:

#1 Adapter will not lock #6 No flow #2 Difficult to insert / remove adapter #7 Equipment in use / unable to test #3 Leak with adapter inserted #8 Control Panel Leaks #4 Leak without adapter inserted #9 No hose present #5 Reduced flow #10 Outlet missing parts

#11 Outlet broken / malfunctioning

HEALTH CHOICE ENTERPRISES, LLC

OUTLET ISSUES

NOTE: THE OUTLETS LISTED AS LEAKING ARE NOT AFFECTING PATIENT CARE AND ARE NOT CREATING ANY ENVIRONMENTAL HAZARDS. MAINTENANCE IS LEFT

TO THE DISCRETION OF THE FACILITY. REFERENCE NFPA 99 2021

MEDICAL GAS

ANALYSIS

APRIL 3rd, 2024

Eugene J. Towbin VA Healthcare Center

2200 Fort Roots Dr.

North Little Rock, AR 72114

Health Choice Enterprises, LLC 4350 Brownsboro Rd. Suite 133

MEDICAL GAS ANALYSIS

APRIL 2024

SPINE COVER

Health Choice Enterprises, LLC 4350 Brownsboro Road Suite 133 Louisville, KY 40207

The following report details the findings from the annual Medical Gas Inspection which follows the recommendations set forth by the NFPA 99 2021, The Joint Commission EC 02.05.09, CMS, and any other applicable local or state requirements.

Annual Report includes:

All annual tests recommended by the ASSE 6000 D3.5 & D3.6 All annual tests required by NFPA 99 2021 - 5.1.14* Category 1 Operation and Management.

All testing of non-stationary booms per 5.1.6.11 Manufactured Assemblies Employing Flexible Connection(s) Between the User Terminal and the Piping System (where applicable).

Annual Report excludes:

Preventative maintenance reports, these test are detailed by the PM provider.

5.1.14.4.3 An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity. Bulk capacity requirements are monitored by Bulk supplier (where applicable).

Reporting format:

• Test Report page describes the systems in use at this Facility and the components tested.

• Master Alarm panel tab describes the findings during testing.

• Source evaluation tabs include an evaluation checklist of all of the components tested per NFPA guidelines. These tabs include Bulk gases (where applicable), container or cylinder manifolds for each gas, Medical air compressor supply systems (where applicable) and Vacuum pump supply systems.

• Zone analysis tabs start by listing the floor. Each subsequent page will list a zone valve and the alarm which serves this same zone or area. The outlet page which follows the zone valve / area alarm page will list all patient outlets / inlets that are served by the valve / alarm.

• Test Procedures lists the components inspected and the parameters tested

• Recommendation section lists any systems that do not meet and the NFPA 99 code and should be evaluated by the facility or AHJ. Any corrections made by the facility or by others, should be noted in the “deficiency corrected” column.

• Observation section lists components of the Facility that are not current NFPA 99 2021 compliant, however they are permitted to remain in use until the areas are upgraded or renovated. These non-current code compliant issues are typically original to the building and were compliant at the time of installation.

They also do not represent a safety risk to patient care or staff. Please reference NFPA 99 2021 section 5.1.1.4* 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.

Testing Credentials Required per NFPA 99 2021:

5.1.12.4.1.3 Testing shall be conducted by a party technically competent and experienced in the field of medical gas and vacuum pipeline testing and meeting the requirements of ASSE 6030, Professional Qualifications Standard for Medical Gas Systems Verifiers.

HCE Technician Name: Jeff Himmelrich

HCE Technician’s Credentials: ASSE 6030 - Cert # 12537183

Signature:

N = Nitrogen

V = Vacuum

Other Gas

MASTER ALARM

PURITY (Contamination) * C = Carbon Dioxide

PARTICULATE **

O, A, V

O, A

O, A, V

N/A

W = Waste Anesthetic Gas

O, A, V

MEDICAL GAS & VACUUM PIPING ONSITE TEST REPORT

Health Choice Enterprises certifies that all items listed within report have been inspected and tested and were in compliance on the date tested to N.F.P.A. 99, AIA and CGA guidelines except for those items so indicated in this Test Report.

FACILITY CONTACT:

ADDRESS: 2200 Fort Roots Dr.

North Little Rock, AR 72114

ARNOLD PALMER

* White Cloth Particulate Test ** Samples taken with 0.45 micron filters

Job Description: TESTED ALL MEDICAL GAS COMPONENTS IN THE HOSPITAL INCLUDING: SOURCE EQUIPMENT, ALL ALARMS, FLEXIBLE CONNECTORS, OUTLETS AND ZONE VALVES PER NFPA 99 2021.

Comments: THIS ANNUAL INSPECTION WAS PERFORMED, BASED ON THE NFPA 99 2021 EDITION. IF YOUR FACILITY OR CERTAIN AREAS OF YOUR FACILITY, WERE CONSTRUCTED OR REMODELED PRIOR TO THE 2021

EDITION, THE AUTHORITY HAVING JURISDICTION SHOULD DECIDE WHETHER TO CORRECT THE

DEFICIENCIES OR UPGRADE THE AREAS TO MEET THE NFPA 99 2021.

Health Choice Enterprises Verifier: Jeff Himmelrich

SYSTEM SYSTEM CODES

PATIENT TERMINALS O, A, V A = Medical Air

ZONE VERIFICATION

ZONE VALVES O, A, V O = Oxygen

ITEM INSPECTED

O, A, V NO = Nitrous Oxide

CROSS CONNECTION

AREA ALARMS

HEALTH CHOICE ENTERPRISES, LLC

MASTER ALARM

PANEL REPORT

Health Choice Enterprises, LLC

4350 Brownsboro Rd. Suite 133

LOCATION: YES

MANUFACTURER:

MODEL:

SYSTEM NFPA

REQUIREMENT ALARM VISUAL

INDICATOR

AUDIBLE

INDICATOR

PROPERLY

LABELED PASS / FAIL COMMENTS

DEW POINT HIGH 5.1.9.2.4(10) Y Y Y Y PASS

CARBON MONOXIDE HIGH 5.1.9.5.4(2) Y Y Y Y PASS

LAG PUMP IN USE 5.1.9.5.4(1) Y Y Y Y PASS

LINE PRESSURE LOW 5.1.9.2.4(7) Y Y Y Y PASS ALARMS AS LINE

PRESSSURE ABNORMAL

LINE PRESSURE HIGH 5.1.9.2.4(7) NO NO NO N/A FAIL ALARM MISSING

PRIMARY LIQUID LEVEL LOW 5.1.9.2.4(2) Y Y Y Y PASS

RESERVE IN USE 5.1.9.2.4(3) Y Y Y Y PASS

RESERVE LIQUID LEVEL LOW 5.1.9.2.4(5) Y Y Y Y PASS

RESERVE PRESSURE LOW 5.1.9.2.4(6) Y Y Y Y PASS

LINE PRESSURE LOW 5.1.9.2.4(7) Y Y Y Y PASS

LINE PRESSURE HIGH 5.1.9.2.4(7) Y Y Y Y PASS

LINE PRESSURE LOW 5.1.9.2.4(7) NO

LINE PRESSURE HIGH 5.1.9.2.4(7) NITROUS

RESERVE IN USE 5.1.9.2.4(1) OXIDE

LINE PRESSURE LOW 5.1.9.2.4(7) NO

LINE PRESSURE HIGH 5.1.9.2.4(7) NITROGEN

RESERVE IN USE 5.1.9.2.4(1)

LINE PRESSURE LOW 5.1.9.2.4(7) NO

LINE PRESSURE HIGH 5.1.9.2.4(7) CARBON

RESERVE IN USE 5.1.9.2.4(1) DIOXIDE

LINE PRESSURE LOW 5.1.9.2.4(8) Y Y Y Y PASS

LAG PUMP IN USE 5.1.3.7.8 Y Y Y Y PASS

SEE ABOVE

#1 Line pressure abnormal #6 Audible alarm not functioning #2 Green / Red Light not functioning #7 In need of calibration #3 Emergency instructions missing #8 Pressure switches piped on wrong side of zone valves #4 Service Required #9 Required alarm is not present #5 Visual alarm not functioning #10 Insufficient / Incomplete / Outdated Labeling

COMMENTS:

MEDICAL AIR

OXYGEN

NITROUS OXIDE

NITROGEN

CARBON DIOXIDE

VACUUM

MEETS CURRENT NFPA 99 2021

ALERT

MASTER ALARM PANEL REPORT

BOILER ROOM POWER LIGHT FUNCTIONAL:

AMICO

LOCATION: YES

MANUFACTURER:

MODEL:

SYSTEM NFPA

REQUIREMENT ALARM VISUAL

INDICATOR

AUDIBLE

INDICATOR

PROPERLY

LABELED PASS / FAIL COMMENTS

DEW POINT HIGH 5.1.9.2.4(10) Y Y Y Y PASS

CARBON MONOXIDE HIGH 5.1.9.5.4(2) Y Y Y Y PASS

LAG PUMP IN USE 5.1.9.5.4(1) Y Y Y Y PASS

LINE PRESSURE LOW 5.1.9.2.4(7) Y Y Y Y PASS ALARMS AS LINE

PRESSSURE ABNORMAL

LINE PRESSURE HIGH 5.1.9.2.4(7) NO NO NO N/A FAIL ALARM MISSING

PRIMARY LIQUID LEVEL LOW 5.1.9.2.4(2) Y Y Y Y PASS

RESERVE IN USE 5.1.9.2.4(3) Y Y Y Y PASS

RESERVE LIQUID LEVEL LOW 5.1.9.2.4(5) Y Y Y Y PASS

RESERVE PRESSURE LOW 5.1.9.2.4(6) Y Y Y Y PASS

LINE PRESSURE LOW 5.1.9.2.4(7) Y Y Y Y PASS

LINE PRESSURE HIGH 5.1.9.2.4(7) Y Y Y Y PASS

LINE PRESSURE LOW 5.1.9.2.4(7) NO

LINE PRESSURE HIGH 5.1.9.2.4(7) NITROUS

RESERVE IN USE 5.1.9.2.4(1) OXIDE

LINE PRESSURE LOW 5.1.9.2.4(7) NO

LINE PRESSURE HIGH 5.1.9.2.4(7) NITROGEN

RESERVE IN USE 5.1.9.2.4(1)

LINE PRESSURE LOW 5.1.9.2.4(7) NO

LINE PRESSURE HIGH 5.1.9.2.4(7) CARBON

RESERVE IN USE 5.1.9.2.4(1) DIOXIDE

LINE PRESSURE LOW 5.1.9.2.4(8) Y Y Y Y PASS

LAG PUMP IN USE 5.1.3.7.8 Y Y Y Y PASS

SEE ABOVE

#1 Line pressure abnormal #6 Audible alarm not functioning #2 Green / Red Light not functioning #7 In need of calibration #3 Emergency instructions missing #8 Pressure switches piped on wrong side of zone valves #4 Service Required #9 Required alarm is not present #5 Visual alarm not functioning #10 Insufficient / Incomplete / Outdated Labeling

VACUUM

MEETS CURRENT NFPA 99 2021

COMMENTS:

MEDICAL AIR

OXYGEN

NITROUS OXIDE

NITROGEN

CARBON DIOXIDE

MASTER ALARM PANEL REPORT

1B NURSES STATION POWER LIGHT FUNCTIONAL:

AMICO

ALERT

OXYGEN SYSTEM

SOURCE EVALUATION

Health Choice Enterprises, LLC

4350 Brownsboro Rd. Suite 133

BULK OXYGEN SOURCE EVALUATION

BULK OXYGEN

SOURCE EVALUATION

2021 STANDARD

The data on this sheet is for PRIMARY and RESERVE supply.

CAPACITY

Yes No N/A

1. Does the storage location have a total capacity greater than 20,000 cu. ft. including unconnected reserve?

(I.E.: 175 gallons liquid or 71 “H” cylinders). If so, it shall comply with NFPA 55, 2005?

ENCLOSURE / LOCATION

2. Is the bulk storage located above ground out of doors OR in a detached fire resistive building which is adequately vented and used only for this purpose?

3. Is the bulk site location used exclusively for nonflammable medical gas equipment and storage?

4. Is the bulk site location readily accessible to mobile supply equipment?

5. Is the ground surface area in the vicinity of the liquid fill connection noncombustible material and extends at least 3 ft. from possible exposure to liquid Oxygen?

Yes No

a) Is the approximate distance is 5 ft.?

b) Is the ground surface area under any mobile supply equipment the full width of the truck and at least 8 ft. in the direction of vehicle axis from the Oxygen fill port?

c) Do concrete or crushed stone completely fill the enclosed space at the bulk site?

d) Are the equipment pad and vehicle pad sloped to provide drainage away from any building, parked vehicles, or combustible materials?

6. Is the bulk storage site enclosure adequately vented with openings at the base of impermeable walls?

7. Is the bulk storage site enclosure adequately secured against physical damage and tampering?

8. Is the bulk site enclosure (wall or fencing) constructed of noncombustible materials?

9. The following are the required distances from exposures for the bulk Oxygen storage container:

Yes No

a) Is the bulk Oxygen system located at least 50 feet from buildings of wood frame construction?

b) Is the bulk Oxygen piping located at least 10 feet from openings in walls of adjacent structures?

c) Is the bulk Oxygen system located at least 5 ft. from property lines?

d) Is the bulk Oxygen system located at least 10 ft. from public sidewalks and parked vehicles?

e) Is the bulk Oxygen system located at least 50 ft. from places of public assembly?

f) Is the bulk Oxygen primary pressure relief discharge and fill/vent connection located 50 ft. from areas occupied by non-ambulatory patients?

g) Is the bulk Oxygen system located 25 ft. from all classes of flammable/combustible liquid storage above ground? (50 ft. from flammable storage over 1000 gallons.)

Yes No

h) Is the bulk Oxygen system located 15 ft. from al classes of flammable /combustible liquid storage below ground and 25 ft. from filling and vent connections?

i) Is the bulk Oxygen system located 50ft from solid rapid burning materials, such as paper?

j) Is the bulk Oxygen system located 25 ft. from solid slow burning materials, such as timber or coal?

k) Is the bulk Oxygen equipment pad and vehicle pad located 8 ft. from the inlet to underground sewer or drainage systems?

l) Is the bulk Oxygen system located more than 5 ft. from under power-lines?

m) Are leaves, weeds, dry grass, and debris cut back or kept at least 15 feet from the bulk oxygen storage container?

n) Is the bulk site located at least 50 ft from the edge of a heliport?

o) Is there at least 3 feet of clearance around all components of the system for operation and maintenance purposes?

EQUIPMENT

Yes No N/A

10. Are the fill connection, top and bottom fill valves, hose purge valve, vent valve, full try/cock, Liquid Level gauge and tank pressure gauge accessible and readily visible to delivery personnel during filling operations?

11. Does the fill circuit have a means to cap and secure the fill connection?

12. Are there at least two main vessel relief valves and rupture disks installed downstream of a three-way valve?

13. Is there a check valve in the primary supply main upstream of the intersection with the secondary or reserve main?

14. Is there a check valve to prevent backflow into the reserve supply?

15. Is reserve economizer piped in previous to final line regulators?

16. Is there a liquid Oxygen vaporizer?

Yes No

a) Are there vaporizer relief valves as required?

17. Are relief valves installed to avoid exhausting on personnel, containers, or toward enclosed spaces?

18. Are relief valves installed to keep out precipitation and prevent malfunction due to freezing or ice accumulation? (Turned down)

19. Are all components of supply system anchored firmly to the concrete equipment pad?

20. Are final line regulators duplexed with a manually operated shutoff valve upstream of each regulator and a shutoff valve or a check valve downstream to permit uninterrupted service?

21. Is a pressure relief valve set at 50% above normal line pressure, downstream of each regulator and upstream of the source valve?

22. Was installation performed by personnel familiar with proper practices for construction of cryogenic liquid systems?

Yes No N/A

23. Are there adequate operating instructions present as required?

24. Are all container connections, controls, valves, and gauges permanently tagged/labeled and/or a schematic drawing attached to the container identifying their function?

25. Is bulk site equipment leased? NOTE: Leased Bulk Equipment alarms and alarm signals must be maintained by the supplier. If this is the case, alarm information below will be marked N/A.

26. Is the system inspected annually and maintained by a qualified representative of the equipment owner?

27. Are the following present?

Bulk Primary System:

Yes No

1. Is there a liquid level indicator?

2. Is there an actuating pressure switch?

Bulk Reserve System:

Yes No

1 Is there a liquid level indicator?

2. Is there an actuating pressure switch?

28. Are there local visual signals for the previous alarms?

Yes No

a) Are they wired to the master alarms?

29. Is there a high/low line pressure master alarm pressure switch?

Yes No

a) Is it wired to the master alarms?

Yes No

a) Is the switch located on the patient side of the main valve, or source valve if there is no main valve?

b) Is the switch connected with a demand check fitting?

c) Is the demand check fitting gas specific?

d) Is there a gauge installed next to the switch after the source / mainline shutoff valve?

30. Is an emergency oxygen supply connection present?

Yes No

a) Is it located on the exterior of the building where it is accessible to emergency supply vehicles in all weather conditions?

b) Is it physically protected to prevent tampering and unauthorized access?

31. Is the source piping appropriately labeled for gas served with standard designation colors?

32. Is the source valve installed in the immediate vicinity of the source equipment?

Yes No

a) Is the valve a three-piece ball valve with indicating handle and brazing extensions?

Yes No N/A

33. Does a mainline shutoff valve exist where the main first enters the building if oxygen supply is remote?

Yes No

a) Is it labeled?

b) Is the valve a three-piece ball valve with indicating handle and brazing extensions?

34. Is the source equipment free of leakage?

DATA

35. Location of source is: BULK PAD

36. Bulk Oxygen supplier is: MESSER Phone number: (800) 232-4726

Primary Liquid Reserve

37. Capacity: (Estimates) 2500 1000

38. Liquid Level: 170 129

39. Liquid Level Scale Range: 0-200

40. Pressure:

0-200

140 119

41. Scale range of gauge: 0-400

42. Source Line Pressure:

0-400

COMMENTS

Reminder: Leased Bulk Equipment alarms and alarm signals must be maintained by the supplier. If this is the case, alarm information will be marked N/A.

EOSC… No Emergency Relief line vented to the outside.

EOSC… Check Valve is not holding pressure.

All alarms on the bulk pad should be tested annually for functionality

MEDICAL AIR SYSTEM

SOURCE EVALUATION

Health Choice Enterprises, LLC

4350 Brownsboro Rd. Suite 133

MEDICAL AIR SOURCE EVALUATION

MEDICAL AIR

SOURCE EVALUATION DATA

2021 STANDARD

GENERAL INFORMATION

1. The data on this sheet is for the following sources: MEDICAL AIR

2. Location of the Medical air equipment is: MECHANICAL ROOM BY THE LOADING DOCK

3. The area served by this source is: ENTIRE 170 BUILDING FACILITY

EQUIPMENT

4. The Compressor Type is: OIL-LESS ROTARY

System Vendor: QUINCY

Unit # Manufacturer Model # Serial # H.P. RPM Hours Run

1 QUINCY QRDS-10 20040131-

10 1760 7076

2 QUINCY QRDS-10 20040131-

10 1760 11132

5. The Dryer Type is: DESSICCANT

Dryer # Manufacturer Model # Serial #

1 QUINCY 201032774 8962

2 QUINCY 201032774 2658

6. MEDICAL AIR INTAKE: Location: FRONT SIDE OF BUILDING Yes No

a) Is the medical air intake source free of contaminants from odor, exhaust, fuel, vacuum discharge, or particulate?

b) Are outdoor intakes located above roof level and at least 25 ft. from any door, window, other intake, exhaust, or opening and a minimum of 20 feet above ground?

c) Is intake piping hard drawn copper?

d) Do the compressors have a means to isolate common intake piping when a compressor is removed for service? NOTE: If the answer is no, a tube cap can be used when compressors are removed from service.

Yes No N/A

7. Is the room adequately vented to prevent accumulation of heat per manufacturers specifications?

8. Is there a dry type intake filter?

9. Does each compressor have a check valve to prevent backflow through off-cycle units?

10. Do the compressors have sufficient isolation valves on the patient side of the compressors?

11. Do the compressors have sufficient anti-vibration mountings?

Yes No N/A

12. Do the compressors have sufficient flex connections for intake and outlet piping?

13. Is the system capable of automatically activating additional units to maintain pressure?

Yes No

a) Is there a Lag Compressor local alarm with audible and visual signals when the last compressor starts?

b) Does the signal latch, requiring manual reset?

c) Is it wired to master alarm?

14. Do controls provide for automatic alternation of units?

Yes No

a) Are motor controls equipped with disconnect switch, motor starting device and overload protection?

b) Are the compressors powered by the equipment branch of the essential electrical system?

15. Is there a Receiver?

Yes No

a) Is the receiver equipped with corrosion resistant material, ASME label, relief valve, automatic drain, manual drain sight glass and 3 valve bypass?

b) Is the receiver equipped with pressure gauge?

16. Are there proper filtration devices which are duplexed with isolating valves?

Yes No

a) Are filters rated for 98% efficiency at 1 micron?

b) Do filters have a visual indicator showing status of the filter element?

Manufacturer: N/A Model: N/A

17. Are there duplexed final line pressure regulators with isolating valves?

18. Is there a 75 psi relief valve located on the patient side of the regulator?

19. Is there a working dew point monitor installed in the Medical Air System?

Yes No Yes No

Is there a visual and audible local alarm? Is it wired to the master alarms?

20. Is there a working carbon monoxide monitor installed in the Medical Air system?

Yes No Yes No

Is there a visual and audible local alarm? Is it wired to master alarms?

21. Do the dew point and CO monitors activate their respective master alarm signals with the loss of power?

22. Is there a valve controlled sample port?

Yes No

a) Is the sample port located between the monitors for dewpoint and CO and the source valve?

23. Is the source valve installed in the immediate vicinity of the source equipment?

Yes No

Is it labeled?

a) Is the source valve located inside the building served? If not a main valve is required.

b) Is the valve a three-piece ball valve with indicating handle and brazing extensions?

Yes No N/A

24. Is there a high/low line pressure master alarm pressure switch?

Yes No

a) Is the switch located downstream of the source and main line valve ( if the same )?

b) Is the switch connected with a demand check fitting?

c) Is the demand check fitting gas specific?

d) Is there a gauge installed next to the switch?

Location of switch: Above the source equipment

Yes No N/A

25. Is the source piping appropriately labeled for gas served with standard designation colors?

26. Does all source piping consist of copper, brass, or stainless steel? (Compressors can have ferrous materials.)

27. Are all copper joints brazed?

28. Is there a preventative maintenance program established for the Medical Air equipment?

29. Are there high head temperature alarm sensors installed?

Yes No

Is there a visual and audible local alarm?

Is it wired to master alarm?

MEDICAL AIR DATA

30. The Medical Air Final Pressure is: 55 psi Gauge range is: 0-100

90 psi and off at: 106 psi 31. The Lead compressor is on at:

32. Dew point reading: -40.0 C @ 55 psi

Dew point monitor Manufacturer: GFG Instrumentation Model: 4021-DP-S Serial: 171015145

33. Is the CO Monitor calibrated at least annually or more often if recommended by the manufacturer?

34. CO reading: 0 PPM

CO monitor Manufacturer: ENMET Model: MedAir 2200 Serial: 100-2271

COMMENTS

The "Medical Air Line Pressure Low" is improperly labeled. It is currently labeled as "Medical Air Line Pressure Abnormal".

The Medical Air Line Pressure High Signal is missing at both Master Alarm Panels (SPS & Boiler Rm).

MEDICAL AIR

PURITY

ANALYSIS

Health Choice Enterprises, LLC

4350 Brownsboro Rd. Suite 133

COMPOUND LIMIT (PPM) LOCATION SAMPLED RESULTS PASS / FAIL

CARBON

MONOXIDE 25 MEDICAL AIR

SAMPLE PORT 1.0 PPM PASS

CARBON DIOXIDE 500 MEDICAL AIR

SAMPLE PORT 450 PPM PASS

HYDROCARBONS

(METHANE) 25 MEDICAL AIR

SAMPLE PORT 0.00 PPM PASS

HYDROCARBONS

(CHLOROFORM) 2 MEDICAL AIR

SAMPLE PORT 0.03 PPM PASS

MEDICAL AIR PURITY TESTING

MEDICAL VACUUM

SYSTEM SOURCE

EVALUATION

Health Choice Enterprises, LLC 4350 Brownsboro Rd. Suite 133

MEDICAL VACUUM SOURCE EVALUATION

MEDICAL VACUUM

SOURCE EVALUATION DATA

2021 STANDARD

Location of source is: MECHANICAL ROOM

System Vendor: QUINCY Model: N/A Serial #: N/A

Pump # Pump Brand Model # Serial # H.P. Hours Run

1 QUINCY QSVB7.5ACN3G 93098J 7.5 6960

2 QUINCY QSVB10WCN3H 95620J 10 75952

Lead pump on at 18 inches Hg. Lead pump off at 21 inches Hg.

Lag pump on at 17 inches Hg. Lag pump off at 21 inches Hg.

Yes No N/A

1. Is the data on this sheet for the following source(s): LEAD & LAG?

2. Is the entire area Facility served by this source?

3. Is the room adequately vented to prevent accumulation of heat per manufacturers recommendations?

4. Are there two or more pumps?

5. Does each pump have a check valve to prevent backflow through off-cycle units?

6. Does each pump have isolation valves on intake piping?

7. Is there sufficient flexible couplings installed in the piping to and from the equipment?

8. Is there a receiver?

Yes No

a) Does the receiver have an ASME data plate?

b) Does the receiver have sufficient manual drain?

c) Is the receiver valved to allow draining or servicing without interrupting the Vacuum system?

9. Is system capable of automatically activating additional units to maintain vacuum?

Yes No

a) Is there a local audible and visual signal when reserve or lag pump is in operation?

b) Does the signal latch, requiring manual reset?

c) Is it wired to master alarm?

10. Is there automatic pump alternation to provide for even wear?

11. Are there dedicated disconnect switches, motor starting devices, and overload protection for each pump?

12. Is power supplied by the equipment branch of the essential electrical system?

MEDICAL VACUUM SOURCE EVALUATION

Yes No N/A

13. Vacuum Exhaust- POINT OF DISCHARGE Yes No

a) Is the exhaust outdoors and at least 25 ft. from any door, window, air intake, or other opening in the building?

b) Is the exhaust discharge turned down and screened or otherwise protected from vermin, debris, or precipitation?

c) Is there a trapped drip leg with valved drain on the exhaust line to discharge condensate or oil?

d) Is the exhaust piping considered to be of proper size to minimize back pressure?

Exhaust location: SIDE OF THE MECHANICAL ROOM Yes No N/A

14. Is Vacuum distribution piping hard-drawn copper or stainless steel pipe?

Yes No

15. Is the source piping appropriately labeled for Vacuum? Is label background color white?

Yes No

16. Is the source valve in the immediate vicinity of the source equipment? Is the source valve labeled?

17. Is there a line pressure low master alarm Vacuum switch?

Yes No

a) Is the switch located on the patient side of the main valve, or source valve if there is no main valve?

b) Is the switch connected with a demand check fitting?

c) Is the demand check fitting gas specific?

d) Is there a gauge installed next to the switch after source / mainline shutoff valve?

Location of switch: ABOVE VACUUM UNIT #2

COMMENTS

There is no dedicated source valve for this vacuum system.

The vacuum switch is not on the line via a DISS fitting connection to allow for service.

The Exhaust discharge is not 25 ft from building openings. Also, not turned down and screened.

Pump #1 one has the same hours reading as last year.

1ST FLOOR

ZONE & OUTLET

ANALYSIS

Health Choice Enterprises, LLC

4350 Brownsboro Rd. Suite 133

INITIALS

SHUTOFF VALVE COMMENTS:

#1 Zone valve is Downstream of another valve #6 Required valve is not present #2 Zone valve is hidden behind door / equipment #7 Frangible Cover Missing / Damaged

#8 Gas labels required #4 Piped backwards, gauge is on source side of valve #9 No Gauge present #5 Valve is leaking while on / operated #10 Insufficient / Incomplete / Outdated Labeling

GAS AUDIBLE

INDICATOR

VISUAL

INDICATOR

GAUGE

READINGS LABELING HIGH LOW COMMENTS DATE

CORRECTED

OXYGEN Y Y 54 Y 60 40

MEDICAL

AIR Y Y 51 Y 60 40

VACUUM Y Y 24 Y 12

#10 Insufficient / Incomplete / Outdated Labeling

#3 Emergency instructions missing #8 Pressure switches piped on wrong side of zone valves #4 Service Required #9 Required alarm is not present #5 Visual alarm not functioning

#2 Green / Red Light not functioning #7 In need of calibration

LOCATION OF ALARM: 1B NURSE STATION

SETPOINTS

INITIALS

ALARM COMMENTS:

#1 Line pressure abnormal #6 Audible alarm not functioning

ADDITIONAL COMMENTS:

ALARM SERVES: 1B: Rms 126, 132, 134, 140, 144, 149, 150, & 159

COMMENTS

#3 Zone valve is in same room as outlets

AREA ALARM TEST & EVALUATION

FLOOR: 1ST

MANUFACTURER: AMICO

ADDITIONAL COMMENTS:

ZONE VALVE AREA LABELED Y Y Y

VALVE TYPE BALL BALL BALL

PRESSURE 56 56 26

VALVE GAS LABELED Y Y Y

ALARM REQUIRED: NO

LOCATION OF VALVE: 1B NURSE STATION

OXYGEN MEDICAL AIR VACUUM DATE CORRECTED

VALVE CONTROLS: 1B: Rms 126, 132, 134, 140, 144, 149, 150, & 159

MEDICAL GAS ZONE VALVES

FLOOR: 1ST

MANUFACTURER: NCG

HEALTH CHOICE ENTERPRISES, LLC

UNDER CONSTRUCTION

UNDER CONSTRCTION

OUTLET STYLE:

FLOOR: AREA:

ROOM

DATE

CORRECTED /

INITIALS

ADDITIONAL COMMENTS

B

Q U A N T I T Y

C O M M E N T S

Q U A N T I T Y

C O M M E N T S

Q U A N T I T Y

C O M M E N T S

1B 126 2 2 2

1B 132 2 2 2

1B 134 2 2 2

1B 140 - LEFT SIDE 2 2 2

1B 140 - RIGHT SIDE 2 2 2

1B 144 - LEFT SIDE 2 2 2

1B 144 - RIGHT SIDE 2 2 2

1B 149 2 2 2

1B 150 2 2 2

1B 159 1 1 1

COMMENTS: #1 Adapter will not lock #5 Reduced flow #9 No hose present #2 Difficult to insert / remove adapter #6 No flow #10 Outlet missing parts #3 Leak with adapter inserted #7 Equipment in use / unable to test #11 Outlet broken / malfunctioning #4 Leak without adapter inserted #8 Control Panel Leaks

NOTE: All terminals Pass & meet the requirements listed, unless otherwise noted.

GAS PURITY

OXYGEN 99%

MEDICAL AIR 19.5 % - 23.5 %

VACUUM N/A

50 - 55 PSIG 3.5 SCFM PATIENT / 6.0 CRITICAL 5 PSIG

12 IN Hg MINIMUM 3.0 SCFM N/A

PRESSURES MINIMUM FLOWRATE MAX PRESSURE DROP

50 - 55 PSIG 3.5 SCFM PATIENT / 6.0 CRITICAL 5 PSIG

MEDICAL GAS OUTLET ANALYSIS

CHEMETRON

1ST 1B

OXYGEN MEDICAL AIR VACUUM

UNDER CONSTRUCTION

INITIALS

SHUTOFF VALVE COMMENTS:

#1 Zone valve is Downstream of another valve #6 Required valve is not present #2 Zone valve is hidden behind door / equipment #7 Frangible Cover Missing / Damaged

#8 Gas labels required #4 Piped backwards, gauge is on source side of valve #9 No Gauge present #5 Valve is leaking while on / operated #10 Insufficient / Incomplete / Outdated Labeling

GAS AUDIBLE

INDICATOR

VISUAL

INDICATOR

GAUGE

READINGS LABELING HIGH LOW COMMENTS DATE

CORRECTED

OXYGEN Y Y 52 Y 60 40

MEDICAL

AIR Y Y 49 Y 60 40

VACUUM Y Y 25 Y 12

#10 Insufficient / Incomplete / Outdated Labeling

#3 Emergency instructions missing #8 Pressure switches piped on wrong side of zone valves #4 Service Required #9 Required alarm is not present #5 Visual alarm not functioning

#2 Green / Red Light not functioning #7 In need of calibration

LOCATION OF ALARM: 1D NURSE STATION

SETPOINTS

INITIALS

ALARM COMMENTS:

#1 Line pressure abnormal #6 Audible alarm not functioning

ADDITIONAL COMMENTS:

ALARM SERVES: 1D: Rms 119, 134, 139, & 149

COMMENTS

#3 Zone valve is in same room as outlets

AREA ALARM TEST & EVALUATION

FLOOR: 1ST

MANUFACTURER: AMICO

ADDITIONAL COMMENTS:

ZONE VALVE AREA LABELED Y Y Y

VALVE TYPE BALL BALL BALL

PRESSURE 54 54 27

VALVE GAS LABELED Y Y Y

ALARM REQUIRED: NO

LOCATION OF VALVE: 1D NURSE STATION

OXYGEN MEDICAL AIR VACUUM DATE CORRECTED

VALVE CONTROLS: 1D: Rms 119, 134, 139, & 149

MEDICAL GAS ZONE VALVES

FLOOR: 1ST

MANUFACTURER: NCG

OUTLET STYLE:

FLOOR: AREA:

ROOM

DATE

CORRECTED /

INITIALS

ADDITIONAL COMMENTS

D

Q U A N T I T Y

C O M M E N T S

Q U A N T I T Y

C O M M E N T S

Q U A N T I T Y

C O M M E N T S

AREA UNDER CONSTRUCTION AT TIME OF

INSPECTION

1D 103 2 2 2

1D 109 2 2 2

1D 139 1 1 1

1D 149 2 2 2

COMMENTS: #1 Adapter will not lock #5 Reduced flow #9 No hose present #2 Difficult to insert / remove adapter #6 No flow #10 Outlet missing parts #3 Leak with adapter inserted #7 Equipment in use / unable to test #11 Outlet broken / malfunctioning #4 Leak without adapter inserted #8 Control Panel Leaks

NOTE: All terminals Pass & meet the requirements listed, unless otherwise noted.

GAS PURITY

OXYGEN 99%

MEDICAL AIR 19.5 % - 23.5 %

VACUUM N/A

50 - 55 PSIG 3.5 SCFM PATIENT / 6.0 CRITICAL 5 PSIG

12 IN Hg MINIMUM 3.0 SCFM N/A

PRESSURES MINIMUM FLOWRATE MAX PRESSURE DROP

50 - 55 PSIG 3.5 SCFM PATIENT / 6.0 CRITICAL 5 PSIG

MEDICAL GAS OUTLET ANALYSIS

CHEMETRON

1ST 1D

OXYGEN MEDICAL AIR VACUUM

INITIALS

SHUTOFF VALVE COMMENTS:

#1 Zone valve is Downstream of another valve #6 Required valve is not present #2 Zone valve is hidden behind door / equipment #7 Frangible Cover Missing / Damaged

#8 Gas labels required #4 Piped backwards, gauge is on source side of valve #9 No Gauge present #5 Valve is leaking while on / operated #10 Insufficient / Incomplete / Outdated Labeling

GAS AUDIBLE

INDICATOR

VISUAL

INDICATOR

GAUGE

READINGS LABELING HIGH LOW COMMENTS DATE

CORRECTED

OXYGEN Y Y 52 Y 60 40

MEDICAL

AIR Y Y 49 Y 60 40

VACUUM Y Y 26 Y 12

#10 Insufficient / Incomplete / Outdated Labeling

VALVE CONTROLS: 1E: Rms 103, 109, 111, 117, 119, 134, 140, & 150

MEDICAL GAS ZONE VALVES

FLOOR: 1ST

MANUFACTURER: NCG

ALARM REQUIRED: NO

LOCATION OF VALVE: 1E NURSE STATION

OXYGEN MEDICAL AIR VACUUM DATE CORRECTED

PRESSURE 55 50 28

VALVE GAS LABELED Y Y Y

ZONE VALVE AREA LABELED Y Y

COMMENTS

VALVE TYPE BALL BALL BALL

ALARM COMMENTS:

#1 Line pressure abnormal

#3 Zone valve is in same room as outlets

AREA ALARM TEST & EVALUATION

FLOOR: 3RD

SETPOINTS

INITIALS

ALARM SERVES: 1E: Rms 103, 109, 111, 117, 119, 134, 140, & 150

ADDITIONAL COMMENTS:

ADDITIONAL COMMENTS:

#5 Visual alarm not functioning

#6 Audible alarm not functioning

#3 Emergency instructions missing #8 Pressure switches piped on wrong side of zone valves #4 Service Required #9 Required alarm is not present

MANUFACTURER: AMICO

#2 Green / Red Light not functioning #7 In need of calibration

LOCATION OF ALARM: 1E NURSE STATION

OUTLET STYLE:

FLOOR: AREA:

ROOM

DATE

CORRECTED /

INITIALS

ADDITIONAL COMMENTS

E

Q U A N T I T Y

C O M M E N T S

Q U A N T I T Y

C O M M E N T S

Q U A N T I T Y

C O M M E N T S

1E 103 - LEFT SIDE 2 2 2 AMICO

1E 103 - RIGHT SIDE 2 2 2 AMICO

1E 109 2 2 2 AMICO

1E 111 2 2 2 AMICO

1E 117 2 2 2 AMICO

1E 119 2 2 2 AMICO

1E 134 2 2 2 500 SERIES

1E 140 1 1 1 500 SERIES

1E 150 1 1 1 400 SERIES

COMMENTS: #1 Adapter will not lock #5 Reduced flow #9 No hose present #2 Difficult to insert / remove adapter #6 No flow #10 Outlet missing parts #3 Leak with adapter inserted #7 Equipment in use / unable to test #11 Outlet broken / malfunctioning #4 Leak without adapter inserted #8 Control Panel Leaks

NOTE: All terminals Pass & meet the requirements listed, unless otherwise noted.

GAS PURITY

OXYGEN 99%

MEDICAL AIR 19.5 % - 23.5 %

VACUUM N/A

MEDICAL GAS OUTLET ANALYSIS

CHEMETRON

1ST 1E

OXYGEN MEDICAL AIR VACUUM

PRESSURES MINIMUM FLOWRATE MAX PRESSURE DROP

50 - 55 PSIG 3.5 SCFM PATIENT / 6.0 CRITICAL 5 PSIG

50 - 55 PSIG 3.5 SCFM PATIENT / 6.0 CRITICAL 5 PSIG

12 IN Hg MINIMUM 3.0 SCFM N/A

HEALTH CHOICE ENTERPRISES, LLC

#7 #7 #7

#7 #7 #7

INITIALS

SHUTOFF VALVE COMMENTS:

#1 Zone valve is Downstream of another valve #6 Required valve is not present #2 Zone valve is hidden behind door / equipment #7 Frangible Cover Missing / Damaged

#8 Gas labels required #4 Piped backwards, gauge is on source side of valve #9 No Gauge present #5 Valve is leaking while on / operated #10 Insufficient / Incomplete / Outdated Labeling

GAS AUDIBLE