Attachment 2 - SOW Appendix A - Boiler Program Plant Assesment.xlsx

XLSX spreadsheet 77 KB Posted Aug 4, 2020

Attached to: H145--National Boiler Contract - Training, Testing, Program and Design document Reviews (VA-20-00058849) Federal contract opportunity
Solicitation number: 36E77620Q0079
Issued by: Department of Veterans Affairs Headquarters

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Other files for this federal contract opportunity

Other files attached to H145--National Boiler Contract - Training, Testing, Program and Design document Reviews (VA-20-00058849), newest first.
File	Type	Posted
Attachment 8 - Technical Question Responses.docx	DOCX document	Aug 13, 2020
Attachment 9 - Standard ES - 2018 - 001.pdf	PDF	Aug 13, 2020
36E77620Q0079 0001.docx	DOCX document	Aug 13, 2020
Attachment 5 - Revised Price Schedule.xlsx	XLSX spreadsheet	Aug 13, 2020
36E77620Q0079_1.docx	DOCX document	Aug 4, 2020
Attachment 5 - Price Schedule.xlsx	XLSX spreadsheet	Aug 4, 2020
Attachment 4 - SOW Appendix C- Program Review Tracking Sheet.xlsx	XLSX spreadsheet	Aug 4, 2020
Attachment 3 - SOW Appendix B - VHA Directive 1810.pdf	PDF	Aug 4, 2020
Attachment 1 - STATEMENT OF WORK (SOW).docx	DOCX document	Aug 4, 2020
Attachment 6- Past Performance Questionnaire (PPQ).docx	DOCX document	Aug 4, 2020
Attachment 7 - Wage Determination Information.pdf	PDF	Aug 4, 2020

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Memphis 2020

Question

GUIDELINES FOR ASSESSING MEDICAL CENTER'S BOILER PLANT PROGRAM

Progress

Goal

Eval Category

Site: Program Review Date:

Category 1 - Management:

1. Management

Response count

Totals

2. Directive

Response count

Totals

3. Training

Response count

Totals

4. Parts & Supplies

Response count

Totals

5. References

Response count

Totals

6. Records

Response count

In general, how does the Medical Center approach the important issues that deal with the boiler plant?

Part

Yes

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Max Points Possible

No - 0 points each

Partial-1 point each

1-1p

Are there written Medical Center or engineering policies that specify a systematic way to address safety device deficiencies in the boiler plant?

Policy

50%

0.5

Policy

67%

0.3333333333

Policy

ERROR:#DIV/0!

Policy

N/A

Policy

1-1a

Are safety device deficiencies in the boiler plant, systematically dealt with in a timely manner? (1-2 months). If not site the evidence that this issue has been elevated to the next higher level for action (Chief Engineer, EOC Committee, local resource board, director, VISN)

Action

88%

0.125

Action

100%

Action

ERROR:#DIV/0!

Action

100%

Action

N/A

Action

1-1d

Are safety device deficiencies tracked to completion in writing with an estimated completion date regardless of cost on a regular and recurring basis? If yes, what mechanism?

Documentation

50%

0.5

Documentation

100%

Documentation

ERROR:#DIV/0!

Documentation

100%

Documentation

90%

0.1

Documentation

Comments:

A written policy is in place that describes the process of dealing with a safety device failure. There is ample evidence of safety device dficiencies being dealt with in a timely manner. All known safety device deficiencies were reported from the BPS through the chief engnieer to the director. There is a safety device deficiency tracking sheet.

1-2p

Is there a policy and SOP in place for training new employees?

1-2a

Are all new employees trained and deemed competent by the Boiler Plant Supervisor and Chief Engineer?

1-2d

Is training of new employees documented in writing? When a new employee is deemed competent, is this signed by BP Supervisor and Chief Engineer?

Comment:

There is a new traiing procedure in place but it hasn’t been fully implemented yet. The procedure should be properly referenced in the engineering boiler plant policy. Trianing is documented but there is no chief engineer delegation of authority to the boiler plant supervisor to deem new operators competent.

1-3a

Does the Directors office approve the quarterly compliance survey? Is there a mechanism to verify its accuracy?

1-3a

Does the Chief Engineer verify and approve the quarterly survey?

1-3a

Does the Boiler Plant Supervisor verify and approve the quarterly survey?

Comments:

Survey is approved by all necessary parties and is reviewed. There is email correspondence to prove verification.

Category 2 - Directive (Current Edition):

Is there evidence that the chief engineer, boiler plant supervisor/leader and boiler plant operators are familiar with and have acted upon the current Boiler Plant Operations Directive (Current Edition)? Is it actively enforced? What is this evidenced by?

Part

Yes

2-1d

Review the facility's quarterly compliance survey posted on CEOSH's Web site: http://vaww.ceosh.med.va.gov/01HE/Pages/DataReports.shtml#Boiler). Is it accurate?

Comments:

Survey is accurate.

2-2p

Is there a policy and SOP in place for notifying the Medical Center Director when a boiler safety is non-functioning?

2-2a

Is the Medical Center Director notified when any boiler safety device is non-functioning, and as a result of the non-functioning safety device/s are interim safety measures put into place and changes to procedures assessed and required due to the non-functioning safety device or device failure?

2-2d

Are the notification and interim safety measures documented in writing and updated when repairs have been made?

Comments:

There is a notification policy, ISMs have been implemented and are documented in writing. Recommend adding clarification in policy about when an ISM should be implemented.

2-3p

Is there a policy and SOP in place for reviewing daily logs?

2-3a

Are daily logs reviewed and actions taken as necessary? Cite evidence.

2-3d

Is there a systematic record of this review?

Comments:

Logs are reviewed by the supervisor on a weekly basis. Boiler plant supervisor initials logs upon review.

2-4p

Is there a lone soul policy and SOP in place for performing safety checks on boiler plant staff?

2-4a

Are safety checks performed and documented by police multiple times per shift on each shift. (maybe via phone, two-way radio, etc.)?

2-4d

Is there record of these safety checks being performed?

Comments:

There is a policy. Checks are performed and documented.

2-5p

Is there a policy in place to update the single line diagrams of the boiler plant when changes occur?

2-5a

Are single line diagrams of the boiler plant equipment and connected loads current and up to date?

2-5d

Is there a document that contains the current revision dates for all boiler plant drawings.

Comments:

A policy is in place in practice drawing are reviewed, updated, and documented.

2-6p	p	Is there a policy for providing and testing emergency power to the boiler plant?	X
2-6a	a	Is there evidence that emergency power system is regularly tested under load?	X
2-6d	d	Is there several years of documentation of the boiler plant emergency power being tested?	X
Comments:		The boiler plant generator is tested and recorded in monthly generator logs. Generators are load banked annually.
2-7p	p	Is there a policy for providing and testing the emergency water source to the boiler plant?
2-7a	a	Is there an emergency water source provided for the boiler plant?
2-7d	d	Is there several years of documentation of the boiler plant emergency water source being tested?
Comments:		There currently is no emergency water source identified for the boiler plant. No policy for testing or maintaining.
2-8p	p	Is there a policy for providing and testing the emergency fuel source to the boiler plant?
2-8a	a	Is the emergency fuel source to the boiler plant tested monthly on every boiler?
2-8d	d	Is there at least a year of documentation of monthly testing of the emergency fuel source?
Comments:

A policy is in place for providing and testing emergency fuel oil source, but policy doesn’t include fuel quality testing. Recommend reevaluating fuel storage requirements to achieve a more accurate storage quantity.

2-9p	p	Is there a policy in place to have current site specific safety device testing procedures in place?
2-9a	a	Do they have written safety device testing procedures specific to their site?
2-9d	d	Is there a change log / record of all past safety device testing procedures as well as the current procedure on file?
Comments:		There is no policy that requires site specific testing procedures. No set of sight specific procedures exist.

Category 3- Training			0	1	2
Is the on-going boiler plant operator training evidenced by?			No	Part	Yes
3-1p	p	Are there current written SOPs for training operators on the operation of boiler plant equipment?
3-1a	a	Have operators been trained on the operation of the boiler plant equipment?
3-1d	d	Is there documentation of operator training on boiler plant equipment?
Comments:		There is an ongoing training cirriculum and training is documented.
3-2p	p	Are there current written SOPs describing how to train operators on emergency situations?
3-2a	a	Are the operators trained yearly in handling emergency situations?
3-2d	d	Is there documentation for each operator in handling emergency situations? (Yearly)
Comments:		Emergency situations are covered in the ongoing training plan.
3-3p	p	Is there a policy requiring operators be trained in the following: OSHA, MSDS, Boiler Plant Operations SOPs, electrical safety, (Lockout-Tag out), call back procedures, and emergency procedures?
3-3a	a	Have all operators been trained in the following: OSHA, MSDS, Boiler Plant Operations SOPs, electrical safety (Lockout-Tag out), call back procedures, and emergency procedures?
3-3d	d	Is there documentation that operators have been trained in the following: OSHA, MSDS, Boiler Plant Operations SOPs, electrical safety (Lockout-Tag out), call back procedures, and emergency procedures? Verify in TMS.
Comments:		There is some training documentation in place, but the training system is new and all training for each operator has not been completed.
Category 4- Parts and Supplies			0	1	2
			No	Part	Yes
4-1p	p	Is there a written policy that addresses having common parts in stock?	X
4-1a	a	Is there an adequate stock of most common parts?			X
4-1d	d	Is there a current inventory list and parts supplier list for the common parts.
Comments:		No policy for keeping spare parts exists. Create a policy that establishes inventory and par levels as well as responsibility. There is an inventory list with par levels.

4-2p	p	Is there a written policy that addresses having emergency parts in stock?
4-2a	a	Is there an adequate stock of emergency parts?
4-2d	d	Is there a current inventory list and parts supplier list for emergency parts?
Comments:		No policy for keeping spare emergency parts exist. Create a policy that establishes inventory and par levels as well as responsibility. There is an inventory list.
4-3a	a	Is the parts storage area organized and accessible?			X
Comments:		The parts storage area is organized and accessible.
4-4p	p	Is there a SOP for acquiring needed materials for the boiler plant (less than and more than $2,500)?	X
4-4a	a	Are all needed materials acquired in a timely manner? If not explain why (what are the problems)?			X
4-4d	d	Is there tracing information, documentation and an estimated time of arrival for parts ordered through contracting?			X
Comments:		There is no boiler plant specific SOP for aquiring needed materials.
Category 5- References			0	1	2
			No	Part	Yes
5-1d	d	Is a hard copy of VA Boiler Plant Directive 1810 on hand or bookmarked and readily available on the computer in the boiler plant?			X
Comments:		A current copy of Directive 1810 is on file.
	d	Are written emergency operating procedures available to operators on all shifts (not locked in office)?		X
Comments:		Some EOPs exist but its not an adequate list. Add more emergency scenarios.

5-3d	d	Are written normal operating procedures available to operators on all shifts (not locked in office)?			X
Comments:		An adequate list of normal operations procedures.
5-4d	d	Are manufacturer’s instructions for all major equipment: boilers, burners, burner management controls, pumps, deaerator, water softener, emergency generator, combustion controls, instrumentation, and schematic boiler control wiring diagrams for troubleshooting readily available?			X
Comments:		References are intact.
5-5d	d	Are records of the last safety device testing inspection, and internal and external inspection of boiler vessels readily available?			X
Comments:		Internal and external inspections are mostly in place. Missed boiler #2 in 2018. NB3477. Significant scale noted on boiler floor tubes for boilers 2 and 3. Safety Device testing documentation is available but there are several discrepacies dealing with proper testing conclusions.
Category 6- Records			0	1	2
			No	Part	Yes
6-1p	p	Is there a policy or SOP for the calibration of temperature indicators and pressure gages used in the boiler plant (boiler pressure, deaerator pressure and temperature, etc.)?		X
6-1a	a	Are instruments calibrated every 6 months and gauges and temperature indicators every year?		X
6-1d	d	Is there a log of calibration dates for temperature indicators and pressure gages used in the boiler plant (boiler pressure, deaerator pressure and temperature, etc.)?			X
Comments:		There is a policy that directs calibration but the policy doesnt direct frequency.A vendor performs gage calibration annually, Instrument calibration is only done annually. Instrument cal must be perfromed semi annually. Calibration data sheets do not contain proper data to evaluate compliance. A log is in place.
6-2p	p	Is there a policy or SOP for the collection and review of daily plant operating logs?			X
6-2a	a	Are daily plant operating logs (steam produced, fuel used, flue gas oxygen, flue gas temperature, steam pressure, deaerator temperature and pressure, other data) being properly collected with hourly readings and operating notes?			X
6-2d	d	Are daily plant operating logs (steam produced, fuel used, flue gas oxygen, flue gas temperature, steam pressure, deaerator temperature and pressure, other data) being maintained with hourly readings and operating notes?			X
Comments:		There is a policy for collecting logs and review. Logs are being properly collected and documented.

6-3d	d	Are boiler inspection reports for current year and past two years readily available?			X
Comments:		Annual Internal inspection and external inspection reports are in place. 2019 and past inspections noted significant scale on boiler tubes.
6-4d	d	Is there evidence that deficiencies listed in the boiler inspection reports or burner and interlock testing reports have been corrected?		X
Comments:		There is evidence of safety device repairs, but not boiler inspection reports.
6-5d	d	Is there evidence that emergency power system is regularly tested under load?			X
Comments:		The generator set is regularly tested.
Category 7 - Physical Observations of Boiler Plant			0	1	2
How often do you visit the plant, walk around and visit with operators (all shifts)			No	Part	Yes
7-1	a	Are the steam safety valve vents discharged outside?			X
Comments:		Safety Valve vent piping is scharged outside.
7-2	a	Are water level gage glasses and sight flow indicators clean on boilers, de-aerator, condensate storage tank, blow-off tank and other equipment?			X
Comments:		All clean
7-3	a	Are boiler water level gage glasses and pressure gages easily visible from main floor in front of boilers?			X
Comments:		Visible
7-4	a	Are electrical and control cabinets closed and locked and all breakers properly labeled?			X
Comments:		Arc flash labeling is good.
7-5	a	How is the overall cleanliness of the boiler plant?			X
Comments:		Boiler plant is average cleanliness.
7-6	a	Do the boiler plant operators work well together? (As a team)			X
Comments:		Operators work well together.
Category 8 - Facility Condition Assessment (FCA)			0	1	2
			No	Part	Yes
8-2	a	In the FCA, are all items graded A,B, or C? (NOTES -for comments only: if not how many items are graded D and/or F? Are there construction projects identified for corrections (Major, Minor, NRM Station Level) to identify these issues?)	X
Comments:		Boiler plant Ds- Replace stacks, condensate tank, DA, Economizer on boiler 1, replace fueloil pump set.
8-3	a	Are there construction projects identified for corrections (Major, Minor, NRM, Station Level) to identify these issues?			X
Comments:		There is a new boiler plant constrction project in skip. NRM funding will be sought.
Category 9 - Testing and Inspection			0	1	2
Are inspections and testing conducted in accordance with the following frequencies?			No	Part	Yes
9-0	a	Does your Qualified Professional Inspector (QPI) meet the minimum criteria?			X
		The inspector is national board certified.
a. Key to Frequency Abbreviations
(1) H = Hourly.
(2) D = Daily. VHA DIRECTIVE 2008-062 CORRECTED COPY October 15, 2008 B-2
(3) M = Once per month.
(4) 6M = Once every 6 months.
(5) Y = Once per year.
(6) 6Y = Once every 6 years.
9-1	a	(1) High pressure boilers (above 15 psig): Inspect furnace and other internal surfaces, closures and accessories. Y			X
Comments:		Internal inspections are performed. Significant scaling was noted on boilers 2 and 3.
9-2	a	(2) High pressure boilers (above 15 psig): Inspect exterior of Unit, casing, supports, closures, accessories, valves, controls. Y			X
Comments:		External inspections are current. No significant issues noted.
9-3	a	(3) Deaerator: Inspection and wet magnetic particle testing of welds of pressure vessel interior. 6Y			X
Comments:		Tank is 50 yrs old and exceeds it useful life but no issues noted on inspection report.
9-4	a	(4) Boiler fouling and combustion gas flow check. Y			X
Comments:		This inspection was performed as a part of the internal inpection.
9-5	a	(5) Tube leak check. Y			X
Comments:		Part of internal inspection.
NOTE: The items preceding (2b(1) through 2b(5) must be accomplished by a Qualified Professional Inspector. The following items (2b(6)) through 2b(13)) must be accomplished by a qualified individual as determined by the medical center’s management. Such a determination must be carefully made for each item and each individual.
9-6	a	(6) Low pressure boilers (15 psig and below): inspect interior and exterior, supports, closures, accessories, valves, and controls. Y
Comments:		N/A
9-7	a	(7) Deaerator: interior cleaning and visual inspection. Y			X
Comments:		No issues noted.
9-8	a	(8) Adjust burner combustion settings and calibrate oxygen trim. 6M			X
Comments:		There are records of tuning. No issues noted.
9-9	a	(9) Check vibration of burner fans. 6M	X
Comments:		No record of this test.
9-10	a	(10) Calibrate instrumentation, monitoring, and control systems. 6M		X
Comments:		There are records. But records are inadequate.
9-11	a	(11) Calibrate pressure gages and thermometers. Y		X
Comments:		Gages are calibrated via vender, but no calibration log is insufficient.
(l2) Operational Testing of Boiler Safety Devices, such as:
9-12a	a	(a) Low-water cutoff (slow drain) M			X
Comments:

Performed monthly.

9-12b	a	(b) Fire each boiler and the pilot on the alternate fuel for 1 hour M			X
Comments:		Monthly fuel oil firing is being performed and documented.
9-12c	a	(c) Low-water cutoff shunt switch M			X
Comments:		This test is being performed monthly.
9-12d	a	(d) Auxiliary low-water cut-off (slow drain) M			X
Comments:		This test is being performed monthly.
9-12e	a	(e) Auxiliary low-water cut-off shunt switch M			X
Comments:		This test is being performed monthly.
9-12f	a	(f) High-water alarm M			X
Comments:		This test is being performed monthly.
9-12g	a	(g) Low-water alarm M			X
Comments:		This test is performed monthly.
9-12h	a	(h) High-steam pressure cut-out (recycle) 6M			X
Comments:		This test is being performed semiannually.
9-12i	a	(i) High-steam pressure cut-out (non-recycle) 6M			X
Comments:		This test is being performed semiannually.
9-12j	a	(j) Steam safety valves (raise boiler pressure until valve pops) 6M			X
Comments:		This test is being performed semiannually.
9-12k	a	(k) Steam safety valves (accumulation test at high fire) Y			X
Comments:		This test is being performed semiannually.
9-12l	a	(l) Flame scanner M			X
Comments:		performed monthly
9-12m	a	(m) Check gas vent for leaks 6M			X
Comments:		This test is being performed semiannually.
9-12n	a	(n) High-gas fuel pressure cut-off 6M			X
Comments:		This test is being performed semiannually.
9-12o	a	(o) Low-gas fuel pressure cut-off 6M			X
Comments:		This test is being performed semiannually.
9-12p	a	(p) Gas fuel safety shut off valves proof of closure 6M			X
Comments:		This test is being performed semiannually.
9-12q	a	(q) Leak test gas fuel safety shut off valves 6M			X
Comments:		This test is being performed semiannually.
9-12r	a	(r) High-fuel oil temperature cut-off (heated fuel) 6M
Comments:		N/A
9-12s	a	(s) Low-fuel oil temperature cut-off (heated fuel) 6M
Comments:		N/A
9-12t	a	(t) Low-atomizing pressure for fuel oil 6M			X
Comments:		This test is being performed semiannually.
9-12u	a	(u) High-fuel oil pressure cut-off 6M			X
Comments:		This test is being performed semiannually.
9-12v	a	(v) Low-fuel oil pressure cut-off 6M			X
Comments:		This test is being performed semiannually.
9-12w	a	(w) Fuel oil safety shut off valves proof of closure 6M			X
Comments:		This test is being performed semiannually.
9-12x	a	(x) Leak test fuel oil safety shut off valves 6M			X
Comments:		This test is being performed semiannually.
9-12y	a	(y) Check operation of Liquid Petroleum Gas pilot 6M			X
Comments:		Test is performed monthly.
9-12z	a	(z) Low-pilot gas pressure cut-out 6M			X
Comments:		This test is being performed semiannually.
9-12aa	a	(aa) Forced draft fan motor interlock 6M			X
Comments:		This test is being performed semiannually.
9-12bb	a	(bb) Forced draft fan damper wide open for purge 6M		X
Comments:		This test is being performed semiannually but conclusion is incorrect.
9-12cc	a	(cc) Boiler outlet damper wide open for purge 6M			X
Comments:		This test is being performed semiannually.
9-12dd	a	(dd) Purge air flow interlock 6M			X
Comments:		This test is being performed semiannually.
9-12ee	a	(ee) Timing for pre-purge 6M			X
Comments:		This test is being performed semiannually.
9-12ff	a	(ff) Timing for post-purge 6M			X
Comments:		This test is being performed semiannually.
9-12gg	a	(gg) Igniter timing 6M			X
Comments:		This test is being performed semiannually.
9-12hh	a	(hh) Low fire position interlock 6M			X
Comments:		This test is being performed semiannually.
9-12ii	a	(ii) Combustion air interlock 6M		X
Comments:		This test is being performed semiannually. Testing conclusion is wrong.
9-12jj	a	(jj) Main flame out; i.e., time to close valves 6M			X
Comments:		This test is being performed semiannually.
9-12kk	a	(kk) Ignition flame out; i.e., it is time to close valves 6M			X
Comments:		This test is being performed semiannually.
9-12ll	a	(ll) Minimum igniter flame test 6M			X
Comments:		This test is being performed semiannually.
9-12mm	a	(mm) Scanner not sensing ignition spark 6M			X
Comments:		This test is being performed semiannually.
9-12nn	a	(nn) Low-oxygen alarm and/or cut-out 6M			X
Comments:		This test is being performed semiannually.
9-12oo	a	(oo) Pre-purge setting of flue gas recirculation damper 6M
Comments:
9-12pp	a	(pp) Interlock of building outside air damper with burner control 6M	X
Comments:		This test is not being performed.
NOTE: The preceding safety devices are essential for ensuring the safest possible operation. Any boilers not so equipped must be immediately programmed for retrofit, with priority given to providing two low water cutoffs per boiler and two fuel safety shut off valves per fuel per boiler. CORRECTED COPY VHA DIRECTIVE 2008-062 October 15, 2008 B-5
(13) Boiler Plant Safety and Operational Duties
9-13a	a	(a) Overall plant operation H		X
Comments:		Logs are missing some directive required hourly data points.

9-13b	a	(b) Blowdown water columns D	X
Comments:		Blowdown daily but not logged.
9-13c	a	(c) Testing and adjusting water treatment D		X
Comments:
9-13d	a	(d) Check furnace pressure 6M		X
Comments:		safety device testing			P259:U261P259:AE261P259:AG261J257P259:S261P259:AH26P259:AI281
9-13e	a	(e) Check combustion gas leaks into boiler room 6M		X
Comments:		Done semi-annually by boiler inspector.
9-13f	a	(f) Clean waterside of boilers Y		X
Comments:		Internal inspection verifies waterside is clean.
9-13g	a	(g) Clean fireside and repair refractory Y		X
Comments:		Internal inspection verifes fireside is clean.
9-13h	a	(h) Operation of deaerator high and low water alarms 6M	X
Comments:		This test is performed monthly.
9-13i	a	(i) Operation of deaerator steam pressure or temperature control 6M	X
Comments:		Daily logs are read in the wrong place.
9-13j	a	(j) Operation of condensate storage tank high and low water alarms 6M	X
Comments:		Performed monthly. Improper conclusion.
9-13k	a	(k) Operation of all other alarm devices M
Comments:		N/A
9-13l	a	(k) Operation of boiler economizers; temperatures in or out H		X
Comments:		hourly
9-13m	d	(m) Review written procedures Y		X
Comments:
9-14p	p	Is there a Policy and SOP for annual and semi-annual safety testing on each boiler?		X
9-14a	a	Is testing being conducted properly and in accordance with the directive / policies?		X
9-14d	d	Is the documentation of the annual and semi-annual being done properly and are several years of data on file?	X
Comments:		Some testing results are incorrect.

Category 10 - Layup and Rotation			0	1	2
			No	Part	Yes
10-1p	P	Is there a general equipment rotation plan (SOP)? If yes, does it include detailed instructions for (FW pumps, Condensate Pumps, Boilers, etc.) and their specified frequencies?	X
		There is no written equipment rotation plan or set schedule.
10-1a	A	Is there evidence that the equipment is being rotated on a fixed schedule?	X
		No fixed schedule.
10-1d	D	Is there two years of equipment rotation documentation?			X
		equipment rotation is captured in the daily log.
10-2p	P	Is there a specific boiler layup SOP. SOP should define the type of layup and specific instructions on how to perform the layup procedure, include instructions on chemical treatment, safety testing, when to lay up the boiler, and how to come out of layup?	X
		No layup SOP.
10-2a	A	Has this facility ever put a boiler into layup?			X
		Yes, but not current practice
10-2d	D	Is there documentation of past boiler layup?			X
		Yes

Directive Score

Progress Policy Action Documentation 0.66666666666666663 1 1 Goal Policy Action Documentation 0.33333333333333337 0 0

Layup and Rotation Score Progress Policy Action Documentation 0 0.5 1 Goal Policy Action Documentation 1 0.5 0

Management Score

Progress Policy Action Documentation 0.5 0.875 0.5 Goal Policy Action Documentation 0.5 0.125 0.5

Training Score Progress Policy Action Documentation 0 0 0 Goal Policy Action Documentation 0 0 0

Parts & Supplies Score Progress Policy Action Documentation 0 1 1 Goal Policy Action Documentation 1 0 0

References Score Progress Policy Action Documentation 0 0 0.9 Goal Policy Action Documentation 9.9999999999999978E-2

Records Score Progress Policy Action Documentation 0.75 0.75 0.9 Goal Policy Action Documentation 0.25 0.25 9.9999999999999978E-2

Physical Observations Score Progress Policy Action Documentation 0 1 0 Goal Policy Action Documentation 0

Facility Condition Assessment Score Progress Policy Action Documentation 0 0.5 0 Goal Policy Action Documentation 0.5

Testing & Inspection Score Progress Policy Action Documentation 1 0.89516129032258063 0.75 Goal Policy Action Documentation 0 0.10483870967741937 0.25

Overall Hospital Score Progress Policy Action Documentation 0.45454545454545453 0.88690476190476186 0.89473684210526316 Goal Policy Action Documentation 0.54545454545454541 0.11309523809523814 0.10526315789473684

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File details come from the government source that posted it. Updated Aug 4, 2020.