Appendix B - Annual Inspection Checklist.pdf

APPENDIX B

NFPA 99 Annual Medical Gas System Components Inspection Checklist

ANNUAL MEDICAL GAS & VACUUM ALARM

SYSTEM INSPECTION CHECKLIST

NFPA 99 (2012 Edition) References: 5.1.9, 5.1.9.1, 5.1.9.2, 5.1.14.2.2

A. GENERAL ALARM SYSTEM REQUIREMENTS

NFPA 99-2012: 5.1.9

☐ Alarm system provided for all required medical gas and vacuum systems ☐ Alarm system continuously monitors system conditions ☐ Alarm system operational and energized ☐ Alarm system not disabled, bypassed, or improperly silenced ☐ Alarm system installed in accordance with NFPA 99 ☐ Alarm signals are both audible and visual ☐ Alarm conditions reset properly once fault is corrected

B. MASTER MEDICAL GAS ALARM PANEL

NFPA 99-2012: 5.1.9.1.1 – 5.1.9.1.7

Location & Accessibility ☐ Located in a continuously occupied location ☐ Accessible to responsible staff ☐ Not located in patient rooms ☐ Free of obstruction or physical damage Labeling ☐ Each gas and vacuum system clearly identified ☐ Alarm indicators labeled for specific monitored conditions ☐ Labels permanent and legible Visual Indicators ☐ Visual alarm activates during simulated fault ☐ Alarm indicator remains illuminated until condition corrected Audible Indicators ☐ Audible alarm activates during simulated fault ☐ Audible alarm clearly distinguishable ☐ Audible alarm silencing functions properly ☐ Visual alarm remains active when audible alarm is silenced

C. ALARM SETPOINTS – PRESSURE & VACUUM

NFPA 99-2012: 5.1.9.1.2

Positive Pressure Medical Gas Systems ☐ High pressure alarm activates at correct setpoint ☐ Low pressure alarm activates at correct setpoint ☐ Alarm activation corresponds to measured pressure Medical Vacuum Systems ☐ Low vacuum alarm activates at correct setpoint ☐ Alarm activation corresponds to measured vacuum

D. SOURCE EQUIPMENT ALARM MONITORING

NFPA 99-2012: 5.1.9.1.3

☐ Source equipment conditions monitored by master alarm ☐ Loss of primary supply alarm activates ☐ Reserve supply alarm activates (if applicable) ☐ Duplex/tri-plex equipment failure alarm activates ☐ Power failure alarm activates (if monitored) ☐ Alarm signals transmit accurately to master alarm panel

E. AREA (ZONE) ALARM PANELS

NFPA 99-2012: 5.1.9.2

Location & Installation ☐ Area alarm installed where required ☐ Area alarm located outside patient care rooms ☐ Alarm accessible and visible to staff Labeling ☐ Zone served clearly identified ☐ Gas or vacuum type clearly labeled ☐ Labels permanent and legible Functional Testing ☐ Alarm activates during simulated pressure loss ☐ Audible and visual indicators function properly ☐ Alarm resets after condition corrected

F. REMOTE ALARM ANNUNCIATION (IF

APPLICABLE)

NFPA 99-2012: 5.1.9.1.6

☐ Remote alarm receives signal from master alarm ☐ Alarm condition displayed correctly

☐ Audible and visual indicators function properly ☐ No signal delay observed

G. ELECTRICAL POWER SUPPLY

NFPA 99-2012: 5.1.9.1.7

☐ Alarm system connected to essential electrical system where required ☐ Alarm system remains operational upon loss of normal power ☐ No evidence of power instability or interruption

H. WIRING & COMPONENT CONDITION

NFPA 99-2012: 5.1.9 (General) ☐ Wiring intact and properly terminated ☐ No exposed or damaged conductors ☐ Sensors and transducers securely installed ☐ No signs of corrosion, moisture, or overheating

I. TESTING & DOCUMENTATION

NFPA 99-2012: 5.1.14.2.2

☐ Alarm system tested at least annually ☐ Actual test results recorded (not pass/fail only) ☐ Alarm setpoints documented ☐ Deficiencies identified and documented ☐ Corrective actions documented or recommended ☐ Inspection date recorded ☐ Inspector name and signature recorded ☐ Inspector qualifications documented

INSPECTOR QUALIFICATIONS

☐ Inspection performed by qualified personnel ☐ ASSE 6040 certification verified ☐ Certification number recorded

ANNUAL ZONE VALVE ASSEMBLY INSPECTION

CHECKLIST

NFPA 99 (2012 Edition) References: 5.1.4.6, 5.1.14.2.2 Identification & Labeling

☐ Zone valve assembly present where required ☐ Valve serves a defined patient care zone ☐ Valve labeled with gas/vacuum type ☐ Valve labeled with rooms/areas served ☐ Labels are permanent and legible Accessibility & Installation ☐ Valve readily accessible ☐ Valve not located inside patient rooms ☐ Valve box unobstructed ☐ No signs of physical damage Valve Operation ☐ Valve fully closes when operated ☐ Valve fully reopens without restriction ☐ No excessive resistance during operation ☐ No leakage detected at valve or fittings System Performance ☐ Pressure/vacuum restored after reopening ☐ No abnormal pressure drop observed ☐ Alarm activation verified (if applicable) Condition ☐ Valve box intact ☐ Piping connections secure ☐ No corrosion, contamination, or debris Documentation ☐ Inspection date recorded ☐ Valve ID/location recorded ☐ Deficiencies documented ☐ Corrective actions noted ☐ Inspector name, signature, ASSE 6040 documented

ANNUAL MEDICAL GAS OUTLET & INLET

INSPECTION CHECKLIST

NFPA 99 (2012 Edition) References: 5.1.4.1, 5.1.14.2.2 Identification & Configuration ☐ Correct gas/vacuum type ☐ Proper indexing ☐ No evidence of cross-connection

☐ Color coding correct ☐ Proper labeling Physical Condition ☐ No physical damage ☐ Faceplate secure ☐ No visible contamination ☐ No corrosion Functional Performance ☐ Proper connection with test adapter ☐ Gas flow present (positive pressure outlets) ☐ Adequate vacuum present (vacuum inlets) ☐ Proper retention of connector ☐ No leakage detected Safety ☐ Outlet not loose or recessed ☐ No foreign materials present Documentation ☐ Outlet/inlet location recorded ☐ Gas/vacuum type recorded ☐ Test results documented ☐ Deficiencies documented ☐ Inspector credentials recorded

ANNUAL HIGH-PRESSURE MEDICAL GAS

MANIFOLD INSPECTION CHECKLIST

NFPA 99 (2012 Edition) References: 5.1.3.5, 5.1.14.2.2 General Configuration ☐ Manifold provided where required ☐ Primary and reserve banks identified ☐ Automatic changeover provided (if required) Location & Environment ☐ Manifold located in compliant room ☐ Adequate ventilation present ☐ Cylinders secured ☐ No combustible materials present Operation

☐ Automatic changeover functions correctly ☐ Manual operation verified (if applicable) ☐ Primary-to-reserve changeover alarm verified Pressure Regulation ☐ Line pressure within NFPA limits ☐ Pressure regulators functioning properly ☐ No pressure creep observed Alarms ☐ Low supply alarm activates ☐ Reserve in use alarm activates ☐ Alarm signals transmit to master alarm Piping & Connections ☐ No leaks detected ☐ Pigtails in good condition ☐ No cracked or damaged hoses Documentation ☐ Cylinder type and size recorded ☐ Alarm test results recorded

☐ ASSE 6040 inspector documented

ANNUAL MEDICAL VACUUM PUMP SYSTEM

INSPECTION CHECKLIST

NFPA 99 (2012 Edition) References: 5.1.3.4, 5.1.14.2.2 System Configuration ☐ Duplex or triplex system provided (if required) ☐ Each pump individually operable ☐ Automatic alternation verified Performance ☐ Adequate vacuum level achieved ☐ Low vacuum alarm activates ☐ Alarm corresponds to actual vacuum Controls & Alarms ☐ Local control panel operational ☐ Pump failure alarm activates

Mechanical Condition ☐ No abnormal noise or vibration ☐ Oil level acceptable (if oil-lubricated) ☐ No visible leaks Exhaust ☐ Exhaust piping intact ☐ Exhaust terminates in approved location Documentation ☐ Vacuum readings recorded ☐ Alarm test results recorded

☐ Corrective actions noted

ANNUAL MEDICAL AIR COMPRESSOR

SYSTEM INSPECTION CHECKLIST

NFPA 99 (2012 Edition) References: 5.1.3.6, 5.1.14.2.2 System Configuration ☐ Duplex or triplex compressors provided ☐ Automatic alternation verified ☐ Reserve capacity available Air Quality ☐ Intake location compliant ☐ Intake filters clean and intact ☐ Dryer operational ☐ Dew point acceptable Performance ☐ System pressure within NFPA limits ☐ Low pressure alarm activates ☐ High pressure alarm activates Controls & Alarms ☐ Local control panel operational ☐ Compressor failure alarm activates

Mechanical Condition

☐ No abnormal vibration or noise ☐ Belts/couplings in good condition ☐ No oil carryover (if applicable) Documentation ☐ Pressure readings recorded ☐ Dew point recorded ☐ Alarm test results recorded

☐ Inspector credentials recorded

INSPECTOR QUALIFICATIONS (ALL SECTIONS)

☐ Inspection performed by qualified personnel ☐ ASSE 6040 certification verified ☐ Certification number documented