SOW_MED_GAS_2025_oneyear.pdf

STATEMENT OF WORK

INSPECTION AND TESTING OF THE PIPED MEDICAL GAS SYSTEMS

INDIAN HEALTH SERVICE

GREAT PLAINS AREA INDIAN HEALTH SERVICE LOCATIONS:

BELCOURT, ND

EAGLE BUTTE, SD

FT. YATES, ND

PINE RIDGE, SD

ROSEBUD, SD

WAGNER, SD

JANUARY 2025

Statement of Work Page 2 Inspection and Testing of the Piped Medical Gas Systems - GPA January 2025

Table of Contents

1. Project Description

2. Scope of Work (SOW):

3. Period of Performance

4. Contractor Responsibilities

5. Government Responsibilities

6. Records/Data

7. Quality Assurance

8. Deliveries or Performance

9. Payments to the Contractor

10. IHS Personnel

11. Invoice Format

12. Authority

Appendix A – Medical Gas Equipment Summary and Locations

Appendix B – Sample Medical Gas Inventory Summary

Appendix C – Sample Deficiency/Recommendation Sheet

Appendix D – Contract Performance Evaluation

Appendix E – Quote Schedule

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January 2025

STATEMENT OF WORK

Inspection and Testing of the Piped Medical Gas Systems Great Plains Area

Belcourt & Ft. Yates, ND, Eagle Butte, Pine Ridge, Rosebud, & Wagner, SD

1. Project Description

A. Title: Inspection and Testing of the Piped Medical Gas Systems

B. Location: This service is to be provided at multiple locations: Belcourt & Ft. Yates, ND, Eagle Butte, Pine Ridge, Rosebud, & Wagner, SD.

C. Period of Performance: Annual Inspections shall be performed no more than 60 days from the Notice to Proceed.

D. Description: The purpose of the contract is to provide an annual inspection and testing of the piped medical gas systems within health care facilities located throughout the Great Plains Area Indian Health Service (North Dakota and South Dakota). It is vital to have the inspection and testing required by code to ensure continued accreditation by the Center for Medicare and Medicaid Services and the Joint Commission of our facilities.

E. Background: Piped medical gas system hazards include the ability of piped oxygen and nitrous oxide to violently enhance fires, patient safety concerns which arise from pressurized gas, simple debris in the pipe, restrictions to flow, the significance of vacuum in medical treatments, and a host of other challenges arising from the increasing complexity and variety of applications for gases in medicine.

F. Related Documents

1. This SOW and any other standard government or IHS documents are included and considered a part of this contract.

2. NFPA 99, Standard for Healthcare Facilities, 2012

G. Common Acronyms or Definitions

1. IHS – Indian Health Service

2. CMS – Centers for Medicare & Medicaid Services

3. CO – Contracting Officer

4. COR – Contracting Officer’s Representative

5. PM – Project Manager

6. IGCE – Independent Government Cost Estimate

7. RFI – Request For Information

2. Scope of Work (SOW): Perform an annual inspection and test of each piped medical gas system located at selected Great Plains Area facilities.

The contractor shall provide all material, labor, equipment and supervision required to accomplish the following:

A. Oxygen System.

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1. Inspect oxygen supply system for proper design, installation, identification, and function.

a. Inspect bulk oxygen system location for all applicable standard compliance.

b. Inspect manifold source supply location for all applicable standard compliance.

2. Inspect source, main, and riser valves for location, labeling, and security.

3. Inspect regulators and pressure relief valves for location and correct values.

4. Test master alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

f. Verify proper operation of all required alarms.

g. Verify all set points.

5. Test area alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

f. Verify current high/low set points.

g. Verify current pressure/vacuum indications with calibrated gauge.

6. Test oxygen system for oxygen concentration at each outlet.

7. Test oxygen for particulate contamination at least once in each zone.

8. Test oxygen system dew point at first outlet in system.

9. Test oxygen system for pressure at supply and at each zone.

10. Test each oxygen outlet for proper function, identification, adaptation, and mechanical integrity.

a. Verify proper operation and condition of each outlet.

b. Verify proper labeling of each outlet.

c. Verify proper operation of valves and that there is no leakage.

i. Identify leaking/malfunctioning outlets.

d. Verify proper operation and condition of latching mechanism.

e. Verify proper operational pressures.

i. Identify outlets delivering substandard pressure/flow rate.

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f. Verify proper static pressures.

11. Test oxygen zone shut-off valves for proper function, identification, and mechanical integrity.

a. Verify proper location/condition.

b. Verify proper labeling.

c. Verify that there is no leakage in zone valve box assembly.

12. Check oxygen pipeline for proper identification labeling.

13. Test each zone for maximum available flow.

a. Test outlet flow rate.

b. Test for pressure drop with high demand.

14. Test each critical care outlet for maximum available flow.

15. Test oxygen system components for leakage.

16. Check oxygen system components for proper installation (NFPA 99).

17. Check for crossed lines.

B. Medical Air System.

1. Inspect medical air source supply for design, installation, location, and identification.

2. Inspect medical air intake for location and fresh air criteria.

3. Inspect dryers, filters, regulators, and pressure relief valve for regulator location and correct values.

4. Inspect source, main, and riser valves for location, labeling, and security.

5. Test master alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

f. Verify proper operation of all required alarms.

g. Verify all set points.

6. Test area alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

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f. Verify current high/low set points.

g. Verify current pressure/vacuum indications with calibrated gauge.

7. Test medical air system gaseous purity.

a. Test at source supply downstream of filters, dryers, and regulators.

b. Test at source sample valve.

8. Test medical air for particulate contamination at least once in each zone.

9. Test source for dew point.

10. Test medical air system for pressure at supply and each zone.

11. Test each medical air outlet for proper function, identification, and mechanical integrity.

a. Verify proper operation and condition of each outlet.

b. Verify proper labeling of each outlet.

c. Verify proper operation of valves and that there is no leakage.

i. Identify leaking/malfunctioning outlets.

d. Verify proper operation and condition of latching mechanism.

e. Verify proper operational pressures.

i. Identify outlets delivering substandard pressure/flow rate.

f. Verify proper static pressures.

12. Test medical air zone shut-off valves for proper function, identification, and mechanical integrity.

a. Verify proper location/condition.

b. Verify proper labeling.

c. Verify that there is no leakage in zone valve box assembly.

13. Check medical air pipeline for proper identification labeling.

14. Test each zone for maximum available flow.

15. Test each critical care outlet for maximum available flow.

a. Test outlet flow rate.

b. Test pressure drop with high demand.

16. Test medical air system components for leakage.

17. Check medical air system components for proper installation (NFPA 99).

18. Check for crossed lines.

C. Nitrous Oxide System.

1. Inspect nitrous oxide supply system for proper design, installation, and function.

2. Inspect source, main, and riser valves for location, labeling, and security.

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3. Inspect regulators and pressure relief valves for location and correct values.

4. Test master alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

f. Verify proper operation of all required alarms.

g. Verify all set points.

5. Test area alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

f. Verify current high/low set points.

g. Verify current pressure/vacuum indications with calibrated gauge.

6. Test nitrous oxide system for concentration.

7. Test nitrous oxide system for particulate contamination.

8. Test nitrous oxide system for pressure at supply and at each zone.

9. Test each nitrous oxide outlet for proper function, identification, and mechanical integrity.

a. Verify proper operation and condition of each outlet.

b. Verify proper labeling of each outlet.

c. Verify proper operation of valves and that there is no leakage.

i. Identify leaking/malfunctioning outlets.

d. Verify proper operation and condition of latching mechanism.

e. Verify proper operational pressures.

i. Identify outlets delivering substandard pressure/flow rate.

f. Verify proper static pressures.

10. Test nitrous oxide zone shut-off valves for proper function, identification, adaptation, and mechanical integrity.

a. Verify proper location/condition.

b. Verify proper labeling.

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c. Verify that there is no leakage in zone valve box assembly.

11. Check nitrous oxide pipeline for proper labeling.

12. Test each nitrous oxide outlet for maximum available flow.

13. Test nitrous oxide pipeline components for leakage.

14. Check nitrous oxide system components for proper installation (NFPA 99).

15. Check for crossed lines.

D. Medical Surgical Vacuum System.

1. Inspect vacuum exhaust for location and environmental considerations.

2. Inspect vacuum source equipment for proper design, installation, and function.

3. Inspect source, main, and riser valves for location, labeling, and security.

4. Test master alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

f. Verify proper operation of all required alarms.

g. Verify all set points.

5. Test area alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

f. Verify current high/low set points.

g. Verify current pressure/vacuum indications with calibrated gauge.

6. Test inches of vacuum at source and at each zone.

7. Test each vacuum inlet for maximum available flow rate SCFM.

8. Test for maximum available flow in all critical care areas.

9. Test each vacuum inlet for proper function, identification, adaptation, and mechanical integrity.

a. Verify proper operation and condition of each inlet.

b. Verify proper labeling of each inlet.

c. Verify proper operation of valves and that there is no leakage.

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i. Identify leaking/malfunctioning inlets.

d. Verify proper operation and condition of latching mechanism.

e. Verify proper operational pressures.

i. Identify inlets delivering substandard pressure/flow rate.

f. Verify proper static pressures.

10. Test all vacuum zone valves for proper function, identification, and mechanical integrity.

a. Verify proper location/condition.

b. Verify proper labeling.

c. Verify that there is no leakage in zone valve box assembly.

11. Check vacuum system components for proper installation (NFPA 99).

12. Check for crossed lines.

E. Dental Air System.

1. Inspect dental air intake for location and fresh air criteria.

2. Inspect dryers, filters, regulators, and pressure relief valve for regulator location and correct values.

3. Inspect source, main, and riser valves for location, labeling, and security.

4. Test dental air system gaseous purity.

5. Test dental air for particulate contamination at least once in each zone.

6. Test each dental air outlet for proper function, identification, adaptation, and mechanical integrity.

a. Verify proper operation and condition of each outlet.

b. Verify proper labeling of each outlet.

c. Verify proper operation of valves and that there is no leakage.

i. Identify leaking/malfunctioning outlets.

d. Verify proper operation and condition of latching mechanism.

e. Verify proper operational pressures.

i. Identify outlets delivering substandard pressure/flow rate.

f. Verify proper static pressures.

7. Test dental air system components for leakage.

8. Check dental air system components for proper installation (NFPA 99).

9. Check for crossed lines.

F. Dental Vacuum System.

1. Inspect dental vacuum exhaust for location and environmental considerations.

2. Inspect dental vacuum source equipment for proper design, installation, and function.

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3. Inspect source and riser valves for proper location, labeling, and security.

4. Test inches of dental vacuum at source and at each zone.

5. Test dental vacuum inlet for maximum available flow rate SCFM.

6. Test each dental vacuum inlet for proper function, identification, adaptation, and mechanical integrity.

a. Verify proper operation and condition of each inlet.

b. Verify proper labeling of each inlet.

c. Verify proper operation of valves and that there is no leakage.

i. Identify leaking/malfunctioning inlets.

d. Verify proper operation and condition of latching mechanism.

e. Verify proper operational pressures.

i. Identify inlets delivering substandard pressure/flow rate.

f. Verify proper static pressures.

7. Check dental vacuum system components for proper installation (NFPA 99).

8. Check for crossed lines.

G. Nitrogen System.

1. Inspect nitrogen supply system for proper design, installation, and function.

2. Inspect source, main, and riser valves for location, labeling, and security.

3. Inspect regulators and pressure relief valves for location and correct values.

4. Test master alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

f. Verify proper operation of all required alarms.

g. Verify all set points.

5. Test area alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

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f. Verify current high/low set points.

g. Verify current pressure/vacuum indications with calibrated gauge.

6. Test nitrogen system for particulate contamination.

7. Test nitrogen system for pressure at supply and at each zone.

8. Test nitrogen system outlets for proper function, identification, adaptation, and mechanical integrity.

a. Verify proper operation and condition of each outlet.

b. Verify proper labeling of each outlet.

c. Verify proper operation of valves and that there is no leakage.

i. Identify leaking/malfunctioning outlets.

d. Verify proper operation and condition of latching mechanism.

e. Verify proper operational pressures.

i. Identify outlets delivering substandard pressure/flow rate.

f. Verify proper static pressures.

9. Test nitrogen zone shutoff valves for proper function, identification, adaptation, and mechanical integrity.

a. Verify proper location/condition.

b. Verify proper labeling.

c. Verify that there is no leakage in zone valve box assembly.

10. Check nitrogen pipeline for proper identification labeling.

11. Test each zone for maximum available flow.

12. Test nitrogen control console for leakage and proper operation.

13. Check nitrogen system components for proper installation (NFPA 99).

14. Check for crossed lines.

H. Carbon Dioxide System.

1. Test area alarms for proper pressure switch location and alarm function.

a. Verify alarm panels are in proper location/condition.

b. Verify emergency electrical power.

c. Verify “POWER ON” indication.

d. Verify functional performance of visual and audible signals.

e. Verify proper labeling.

f. Verify current high/low set points.

g. Verify current pressure/vacuum indications with calibrated gauge.

2. Test carbon dioxide system for concentration.

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3. Test carbon dioxide system for particulate contamination.

4. Test carbon dioxide system for pressure at each zone.

5. Test each carbon dioxide outlet for proper function, identification, adaptation, and mechanical integrity.

a. Verify proper operation and condition of each outlet.

b. Verify proper labeling of each outlet.

c. Verify proper operation of valves and that there is no leakage.

i. Identify leaking/malfunctioning outlets.

d. Verify proper operation and condition of latching mechanism.

e. Verify proper operational pressures.

i. Identify outlets delivering substandard pressure/flow rate.

f. Verify proper static pressures.

6. Check carbon dioxide zone shut-off valves for proper function, identification, and mechanical integrity.

a. Verify proper location/condition.

b. Verify proper labeling.

c. Verify that there is no leakage in zone valve box assembly.

7. Check carbon dioxide pipeline for proper identification labeling.

8. Test each carbon dioxide outlet for maximum available flow.

9. Test carbon dioxide pipeline components for leakage.

10. Check carbon dioxide system components for proper installation (NFPA 99).

11. Check for crossed lines.

I. Addition Facility Requirements: Contractor shall comply with the requirements of the hospital’s Facility Manager and clean up after themselves including any tools and equipment needed to completed the testing.

3. Period of Performance.

A. Annual Inspections shall be performed no more than 60 days from the Notice to Proceed.

B. Following completion of the annual inspections, a copy of each report shall be provided to the Project

Officer for documentation purposes. This documentation shall be provided no later than 20 workdays following the completion of the final site visit and shall be in an organized, legible format. See Section 6 for additional information.

4. Contractor Responsibilities

A. Contractor personnel performing the testing/inspections shall possess appropriate credentials from a certifying organization, such as, Medical Gas Professional Healthcare Organization (MGPHO), National Inspection Testing Certification (NITC), and American Society of Safety Engineers (ASSE). Supporting documentation for credentials shall be submitted with the bid proposal.

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B. Following notice to proceed, the contractor shall submit a proposed inspection schedule to the Project Officer for approval. The schedule shall include: facility locations, date of planned inspections, and the name of each technician to perform each inspection. The contractor shall notify the Project Officer immediately concerning any scheduling changes. The contractor shall notify each Facility Manager a minimum of 72 hours prior to performing a service.

C. Failed component replacement and repairs will not be included within the contractor’s responsibilities unless the failure of components is the result of the contractor’s activities. However, the contractor is invited to provide recommendations resulting from the contracted service to the Facility Manager and the Project Officer. Any repair, service, or part not included within this contract will require a separate procurement from the local Service Unit before the repair, service or part can be performed, installed, or ordered. Invoices without a corresponding procurement number will not be paid.

D. An attempt to test all patient terminals shall be completed. If the terminals are considered to be inaccessible, it shall be verified by the facility manager before completion of the inspection.

5. Government Responsibilities

A. The Facility Manager will provide an escort to accompany the contractor during the inspection. The escort will provide access to all the required areas needed to perform the contracted services. Pre- Construction Meeting: One Pre-Construction meeting shall be conducted prior to the start of the construction of the contract.

6. Records/Data

A. Following completion of the annual inspections, a copy of each report shall be provided to the Project Officer for documentation purposes. This documentation shall be provided no later than 20 workdays following the completion of the final site visit and shall be in an organized, legible format.

B. Reports shall include but not limited to the following:

1. Date of inspection.

2. Name of personnel performing inspection.

3. Testing procedures utilized during inspection.

4. Medical gas inventory summary. [see attached sample]

5. Data obtained from the evaluation.

6. List of deficiencies found but not corrected along with recommendations on correction. [see attached sample]

C. The contractor shall submit one package, after all sites have been visited, containing one invoice that includes all the locations to the Project Officer itemizing the service performed at each site. The invoice shall include the contract number, facility name, type of service performed at each facility, date of service for each facility, and payment amount per facility. The reports shall accompany the invoice.

Individual invoices shall not be submitted to the locations within the contract.

7. Quality Assurance

A. Facility Managers will submit vendor evaluations to the Project Officer upon completion of each site visit

[see attached sample]. Successful contract completion will be determined by timely submission of schedules, reports, and invoices. Accuracy of schedule and information in reports will also be taken into

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January 2025 consideration. Thorough completion of services as indicated in the contractor tasks, vendor evaluations, and in general will also be considered when evaluating the successful completion of the contract.

8. Deliveries or Performance

A. Place of Performance/Hours of Operation

1. Sites to receive service are Eagle Butte (SD), Pine Ridge (SD), Rosebud (SD), Wagner (SD), Belcourt (ND), and Ft. Yates (ND).

2. Inspection and testing shall be completed between the hours of 8:00 AM and 5:00 PM, M-F unless otherwise approved by the Project Officer. No testing and maintenance shall be performed on a national holiday unless approved by the Project Officer.

B. Delivery Dates/Period of Performance

1. Annual inspections shall be performed no more than 60 days from notice to proceed.

9. Payments to the Contractor

1. The Government will pay the Contractor a fixed price, as indicted below, which will constitute full compensation for all Contractor professional and incidental services, travel expenses, and materials necessary to furnish complete project as required and specified in this SOW.

2. Progress payments will be paid following acceptance by the Government of that particular schedule item and a properly submitted and approved invoice.

10. IHS Personnel

Contracting Officer’s Representative (COR)

COR Name will be designated as the Contracting Officer’s Representative (COR) for this Order. His address and telephone are:

COR Name Great Plains Area Indian Health Service Division of Facilities Management & Engineering Address City, ST Zip Code Office: ###-###-#### Email@ihs.gov

Any change in COR designation will be documented by the Contracting Officer in writing.

Project Manager (PM)

Corey Sawatzky is the Project Manager for this contract. His contact information is:

Corey Sawatzky Project Manager Great Plains OEHE Office #: 605-945-5454 Corey.sawatzky@ihs.gov

Commented [SC(1]: Who is going to be the COR on these moving forward?

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11. Invoice Format

Invoice Processing Platform (IPP)

The Indian Health Service (IHS) is in the process of implementing an electronic invoicing system

In compliance with the Office of Management and Budget (OMB) M-15-19 memorandum, Improving

Government Efficiency and Saving Taxpayer Dollars Through Electronic Invoicing, directing Federal agencies to adopt electronic invoicing as the primary means to disburse payment to vendors. Invoices submitted under any award resulting from this solicitation will be required to utilize the Invoice

Processing Platform (IPP) in accordance with HHSAR 352.232-71, Electronic Submission and Processing of Payment Requests.

IPP is a secure, web-based electronic invoicing system provided by the U.S. Department of the Treasury’s

Bureau of the Fiscal Service, in partnership with the Federal Reserve Bank of St. Louis (FRSTL).

Respondents to this solicitation are encouraged to register an account with IPP if they have not already done so. If your organization is already registered to use IPP, you will not be required to re-register-however, we encourage you make sure your organization and designated IPP user accounts are valid and up to date.

The IPP website address is: https://www.ipp.gov

If you require assistance registering or IPP account access, please contact the IPP Helpdesk at (866) 973-

3131 (M-F 8AM to 6PM ET), or IPPCustomerSupport@fiscal.treasury.gov

Should the contractor feel that use of the IPP would be unduly burdensome, their response to this solicitation should include an explanation of this position for a determination by the contracting officer.

12. Authority

A. No person other than the Contracting Officer has authority to bind the Government with respect to this contract.

B. No action or omission of any government employee or representative other than the Contracting Officer shall increase or decrease the scope of this contract or shall otherwise modify the terms and conditions of this contract.

C. In no event shall any of the following be effective or binding on the Government or imputed to the Contracting Officer with respect to this contract:

1. An understanding or agreement between the Contractor and anyone other than the Contracting

Officer;

2. A purported modification or change order issued by anyone other than the Contracting Officer;

3. A promise by anyone other than the Contracting Officer to provide additional funding or make payments; or

4. An order, direction, consent, or permission from anyone other than the Contracting Officer to:

a. Incur costs in excess of a specified estimated cost, allotment of funds, or other ceiling; or

b. Expend hours in excess of a specified level of effort.

https://obamawhitehouse.archives.gov/sites/default/files/omb/memoranda/2015/m-15-19.pdf https://www.ipp.gov/ mailto:IPPCustomerSupport@fiscal.treasury.gov

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Appendix A – Medical Gas Equipment Summary and Locations

Appendix B – Sample Medical Gas Inventory Summary

Appendix C – Sample Deficiency/Recommendation Sheet

Appendix D – Contract Performance Evaluation

Appendix E – Quote Schedule

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Appendix A – Medical Gas Equipment Summary and Locations

Location Alarm Panels

Zone Valve Boxes

Zone Valves Patient Terminals

System Sources

Belcourt, ND

Area: 9

Oxygen: 12 Oxygen: 63 Oxygen Manifold: 1

Medical Air: 9 Medical Air: 45 Medical Air Comp.: 1

Vacuum: 11 Vacuum: 66 Medical Vacuum Pump: 1

Master: 2

Nitrous Oxide: 2 Nitrous Oxide: 4 Nitrous Oxide Manifold: 1

WAGD: 1 Dental Air Compressor: 1

Dental Vacuum Pump: 1

Total: 34 Total: 179

Eagle Butte, SD

Area: 9

Oxygen: 10 Oxygen: 41 Oxygen Manifold: 1

Medical Air: 10 Medical Air: 38 Medical Air Comp.: 1

Master: 2

Vacuum: 10 Vacuum: 41 Medical Vacuum Pump: 1

Dental Vacuum Pump: 1

Total: 30 Total: 120 Dental Air Compressor: 1

Ft. Yates, ND

Area: 3

Oxygen: 4 Oxygen: 20 Oxygen Manifold: 1

Medical Air: 1 Medical Air: 6 Medical Vacuum Pump: 1

Master: 2

Vacuum: 3 Vacuum: 21 Medical Air Comp.: 1

Total: 8 Total: 47

Pine Ridge, SD

Area: 18

Oxygen: 15 Oxygen: 116 Oxygen Bulk Source: 1

Medical Air: 14 Medical Air: 98 Nitrous Oxide Manifold: 1

Vacuum: 15 Vacuum: 134 Medical Air Comp.: 1

Master: 2

Nitrous Oxide: 3 Nitrous Oxide: 7 Medical Vacuum Pump: 1

WAGD: 3 Dental Air Compressor: 1

Dental Vacuum Pump: 1

Total: 47 Total: 358

Rosebud, SD

Area: 10

Oxygen: 13 Oxygen: 118 Oxygen Bulk Source: 1

Medical Air: 12 Medical Air: 71 Medical Air Comp.: 1

Vacuum: 12 Vacuum: 159 Medical Vacuum Pump: 1

Master: 2

Nitrous Oxide: 3 Nitrous Oxide: 9 Dental Vacuum Pump: 1

WAGD: 3 Nitrous Oxide Manifold: 1

Dental Air Compressor: 1

Total: 39 Total: 360

Wagner, SD

Area: 1

Oxygen: 3 Oxygen: 4 Oxygen Manifold: 1

Vacuum: 3 Vacuum: 8 Medical Vacuum Pump: 1

Master: 2 Dental Vacuum Pump: 1

Total: 6 Total: 12 Dental Air Compressor: 1

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Appendix B – Sample Medical Gas Inventory Summary

HOSPITAL NAME

City, State

MEDICAL GAS INVENTORY SUMMARY

Date

Medical Gas Terminal Count

Oxygen 51

Medical Air 38

Medical Vacuum 62

Total Gas Terminals 151

Zone Valves

Total Zone Valve Boxes 9

Oxygen Zone Valves 8

Medical Air Zone Valves 6

Vacuum Zone Valves 7

Total Zone Valves 21

Alarm Panels

Total Area Alarm Panels 7

Total Master Alarm Panels 2

Sources

Oxygen Manifold 1

Medical Air Compressor 1

Medical Vacuum Pump 1

Dental Air Compressor 1

Dental Vacuum Pump: 1

MEDICAL AIR EQUIPMENT

COMP # MANUFACTURER MODEL # SERIAL # H.P. RPM

1 Ohmeda A490MAFBA JV47485 5 1745

2 Ohmeda A490MAFBA JV47485 5 1745

DRYER # MANUFACTURER MODEL # SERIAL # SCFM

1 Squire-Cogswell A-25 2676 25

LEVEL 3 DENTAL VACUUM EQUIPMENT

PUMP # MANUFACTURER MODEL # SERIAL # H.P.

1 Ram Vac 826E.0800.3 BN0406154 3

MEDICAL VACUUM EQUIPMENT

PUMP # MANUFACTURER MODEL # SERIAL # H.P. RPM HOURS RUN

1 Beacon VAL02-104 2617544 7.5 1725 2388

2 Beacon VAL02-104 26211799 7.5 1725 2395

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Appendix C – Sample Deficiency/Recommendation Sheet

HOSPITAL NAME

City, State

OBSERVATIONS/RECOMMENDATIONS

SYSTEM NAME

Date

LOCATION PROBLEM/DESCREPANCY RECOMMENDATION

IMMEDIATE

CORRECTION

ADVISED

REFERENCE

1 Loading Dock Area

The high/low line pressure master alarm pressure switch is not connected with a demand check fitting.

Connect the high/low line pressure master alarm pressure switch with a gas specific demand check fitting.

NFPA 99, 2005;

5.1.8.2.3

2 Surgery Manifold Room

Electrical wall fixtures are not at least 5 feet above floor.

Relocated the electrical wall fixtures, switches and receptacles in a location five feet above the floor to prevent physical damage from movement of cylinders.

NFPA 99, 2005;

5.31.3.3.2(5)

3 Boiler Room

There is not a Lag Compressor local alarm with audible and visual signals when the last compressor starts.

Install a Lag Compressor alarm with audible and visual signals to indicate when lag compressor is in operation that latches and connect it to the master alarms.

NFPA 99, 2005;

5.1.3.5.14.5 5.1.9.5.4(1)

4 Boiler Room

There is not a gauge installed next to the line pressure low master alarm Vacuum switch.

Install a gauge next to the line pressure low master alarm Vacuum switch.

NFPA 99, 2005;

5.1.8.2.2(1)

5 Loading Dock Area

The source piping is not appropriately labeled for gas served with standard designation colors.

Properly label the Oxygen piping with the name of gas served with standard designation colors.

NFPA 99, 2005;

5.1.11.1 Table 5.1.11

6 Boiler Room

There are not duplexed final line pressure regulators with isolating valves.

Purchase a compliant model when equipment is replaced.

NFPA 99, 2005:

5.1.3.5.11.5

NFPA 99, 2005;

5.1.3.5.11.6

Statement of Work Page 20

Appendix D – Contract Performance Evaluation

Great Plains Area Piped Medical Gas Inspection Performance Evaluation

To be completed by Facility Manager after inspection

Facility Name:________________________________________________________________

Date:______________________________ Contractor Rep onsite:___________________

1. Overall Evaluation Poor Average Good Excellent

2. Performance Poor Average Good Excellent

3. Quality of Services Poor Average Good Excellent

4. Workmanship Poor Average Good Excellent

5. Knowledge Poor Average Good Excellent

Comments:

Statement of Work Page 21

January 2025

Appendix E – Quote Schedule

QUOTE SCHEDULE

for

INSPECTION AND TESTING OF THE PIPED MEDICAL GAS SYSTEMS

for the

GREAT PLAINS AREA INDIAN HEALTH SERVICE

Location Price

Belcourt

Eagle Butte

Ft. Yates

Pine Ridge

Rosebud

Wagner

Total Quote:

Bidders are required to respond to all items in the quote schedule including the base and all 4 option years or the bid will be considered non-responsive. Total prices must include testing equipment, labor, overhead, profit, delivery, mobilization and demobilization, and all applicable taxes and fees (federal, state, local, and Tribal), for all piped medical gas systems at IHS Service Unit locations listed in the work statement.