Attachment 2 - SOW Appendix A.xlsx

XLSX spreadsheet 90 KB Posted Aug 13, 2025

Attached to: H145--National Boiler Contract (VA-26-00003371)
Solicitation number: 36C77625Q0261
Issued by: Department of Veterans Affairs Technology Acquisition Center Austin

About this file

Written by GovTribe AI · Aug 13, 2025

This document is a detailed Boiler Plant Program Assessment spreadsheet for a VA Medical Center, providing a comprehensive evaluation of the facility's boiler plant operations across ten critical categories: Management, Directives, Training, Parts & Supplies, References, Records, Physical Observations, Facility Condition Assessment, Testing and Inspection, and Layup and Rotation.

The assessment reveals that while the medical center's boiler plant generally meets operational standards, several improvement areas were identified, including the need to develop specific Standard Operating Procedures (SOPs) for gauge calibration, spare parts inventory management, and equipment rotation. Notable findings include the requirement to perform non-destructive testing on the deaerator tank (overdue by five years), update safety device testing documentation, replace certain safety relief valves, and implement additional safety modifications such as adding a SLAMPS switch to all boilers and relocating fan current relays. The overall hospital score across various assessment categories ranged between 64-94%, indicating a generally compliant but not fully optimized boiler plant operation.

View the file

Other files

File	Type	Posted
Attachment 4 - SOW Appendix C -VHA Boiler and Associated Plant Safety Device Testing Manual 8th Edition.pdf	PDF	Aug 13, 2025
Attachment 5 - Price Schedule.xlsx	XLSX spreadsheet	Aug 13, 2025
Attachment 3 - SOW Appendix B VHA Boiler Directive 1810.pdf	PDF	Aug 13, 2025
Attachment 1 - National Boiler SOW Final.docx	DOCX document	Aug 13, 2025
36C77625Q0261.docx	DOCX document	Aug 13, 2025

On GovTribe

Work with this file

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

VA Medical Center BPR

Question

Chief Engineer

B. P. Super

Operators

BEI Staff Evaluation

Hosp Director

union

GUIDELINES FOR ASSESSING MEDICAL CENTER'S BOILER PLANT PROGRAM

Site Response

Progress

Goal

Eval Category

Safety Champion

Site: VA Medical Center Program Review Date:

Action plan

Expected Abatement Date

Closeout 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

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

1-1p

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

Procedure

100%

Procedure

69%

0.3125

Procedure

100%

Procedure

1-1a

Are safety device deficiencies in the boiler plant, systematically dealt with in a timely manner? (1-2 months). If not, cite 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

100%

Action

88%

0.125

Action

100%

Action

100%

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

100%

Documentation

61%

0.3888888889

Documentation

100%

Documentation

33%

0.6666666667

Documentation

SOP VHA-VXX-Station-FMS-SOP-BP01 describes a systematic notification criteria in the event of a safety device malfunction. There is also a procedure for how to manage the boilers with failed safety devices. The site deals with safety device deficiencies in a timely manner and does maintain an annual safety device failure tracking sheet.

1-2p

Is there a 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 an SOP in place for onboarding new employees. The process was implemented on a new hire employee, but the new hire employee did not complete the program before official certification could be made, The infrastructure to handle a new operator is in place.

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:

There is evidence that the chief engineer and boiler plant supervisor certify the survey. There is evidence that the survey is transmitted to the directors office and certified. There is a VISN wide extraview process to handle the quarterly compliance survey.

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 HEFP's Web site. Is it accurate?

Comments:

The survey is accurate and complete.

2-2p

Is there a 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 an SOP in place for notifying the directror. ISMs have been implemented and certifed by the Director.

2-3p

Is there a 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:

There is an SOP in place for review. Supervisor reviews boiler logs on regular basis but does not sign or date to certify the review. Boiler plant supervisor must certify when reviewing the log to show systematic record of review.

2-4p

Is there a lone soul 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 procedure in place for performing health and wellness checks and for managing the boilers in the event of an incapacitated operator. Health and wellness checks are performed by the VA police, but is not recorded every two hours. The logs are maintained by the police. The logs simply state at the end of the shift that all checks have been made.

2-5p

Is there a procedure 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:

There is no procedure for maintaining single line diagrams. The procedure must detail the process of maintaining and updating single line diagrams. Single line diagrams are in place. No document contains revision dates or a change log.

2-6p

Is there a procedure for providing and testing emergency power to the boiler plant?

2-6a

Is there evidence that emergency power system is regularly tested under load?

2-6d

Is there several years of documentation of the boiler plant emergency power being tested?

Comments:

The boiler plant has a dedicated boiler plant generator. The generator is located outside of the boiler plant but the control panel and ATS is located in the boiler plant. Currently the boiler plant operator has no generator responsibility. An SOP is in place for providing and testing emergency power. Testing logs are in palce. Generator is load banked annually.

2-7p

Is there a procedure for providing and testing the emergency water source to the boiler plant?

2-7a

Is there an emergency water source provided for the boiler plant?

2-7d

Is there several years of documentation of the boiler plant emergency water source being tested?

Comments:

There is an SOP for providing emergecny water to the boiler plant. There are two feeds into the boiler plant. There is a water tower that has 750,000 gallons of storage and an additional 400,000 gallon ground level storage. The entire faciity is served by two onsite water wells and an onsite water treatment facility. There is an emergency water connection in place. This third connection isnt function tested. Periodically the ability to use this third connection must be verified. Create an SOP for this emergency water feed function testing.

2-8p

Is there a procedure for providing and testing the emergency fuel source to the boiler plant?

2-8a

Is the emergency fuel source to the boiler plant tested monthly on every boiler?

2-8d

Is there at least a year of documentation of monthly testing of the emergency fuel source?

Comments:

There is approximately 120,000 gallons of storage available. Estimated requirement is approximatley 45,000 gallons for 10 day supply. There is currently approx. 121,000 gallons on hand. There is an SOP in place. Fuel function testing is performed and fuel is quality tested annually.

2-9p

Is there a procedure in place to have current site specific safety device testing procedures in place?

2-9a

Do they have written safety device testing procedures specific to their site?

2-9d

Is there a change log / record of all past safety device testing procedures as well as the current procedure on file?

Comments:

Site specific testing procedures are in place.

Category 3- Training

Is the on-going boiler plant operator training evidenced by?

Part

Yes

3-1p

Are there current written SOPs for training operators on the operation of boiler plant equipment?

3-1a

Have operators been trained on the operation of the boiler plant equipment?

3-1d

Is there documentation of operator training on boiler plant equipment?

Comments:

Training is both OJT and media based. Training records are in place.

3-2p

Are there current written SOPs describing how to train operators on emergency situations?

3-2a

Are the operators trained yearly in handling emergency situations?

3-2d

Is there documentation for each operator in handling emergency situations? (Yearly)

Comments:

Training is both OJT and media based for emergency scenarios. Training records are in place.

3-3p

Is there a procedure 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

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

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:

TMS training is current.

Category 4- Parts and Supplies

Part

Yes

4-1p

Is there a written procedure that addresses having common parts in stock?

4-1a

Is there an adequate stock of most common parts?

4-1d

Is there a current inventory list and parts supplier list for the common parts.

Comments:

Adequate parts inventory is in place. A SOP is not in place. Create a SOP that describes how to maintain spare parts inventory. Complete inventory list is not in place. Create inventory list.

4-2p

Is there a written procedure that addresses having emergency parts in stock?

4-2a

Is there an adequate stock of emergency parts?

4-2d

Is there a current inventory list and parts supplier list for emergency parts?

Comments:

Adequate parts inventory is in place. A SOP is not in place. Create a SOP that describes how to maintain spare parts inventory. Complete inventory list is not in place. Create inventory list.

4-3a

Is the parts storage area organized and accessible?

Comments:

The area is accessible and organized.

4-4p

Is there a SOP for acquiring needed materials for the boiler plant (less than and more than $2,500)?

4-4a

Are all needed materials acquired in a timely manner? If not explain why (what are the problems)?

4-4d

Is there tracing information, documentation, and an estimated time of arrival for parts ordered through contracting?

Comments:

There is no official SOP for aquiring spare parts available in the boiler plant. Internal tracking in place.

Category 5- References

Part

Yes

5-1d

Is a hard copy of VA Boiler Plant Directive 1810 on hand or bookmarked and readily available on the computer in the boiler plant?

Comments:

5-2d

Are written emergency operating procedures available to operators on all shifts (not locked in office)?

Comments:

Emergency operations procedures are in place.

5-3d

Are written normal operating procedures available to operators on all shifts (not locked in office)?

Comments:

Some Normal operations procedures are in place but not a complete library in an organzied format.

5-4d

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?

Comments:

5-5d

Are records of the last safety device testing inspection, and internal and external inspection of boiler vessels readily available?

Comments:

Internal / External pressure vessel inspection reports are available. Safety device testing documentation is in place.

Category 6- Records

Part

Yes

6-1p

Is there a SOP for the calibration of temperature indicators and pressure gages used in the boiler plant (boiler pressure, deaerator pressure and temperature, etc.)?

6-1a

Are instruments calibrated every 6 months and gauges and temperature indicators every year?

6-1d

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.)?

Comments:

There is no SOP in place for gauge calibration. Gauges are calibrated in house. Calibration is documented by stickers on the gauges. A log of all devices with calibration data and certifications is needed. No instrumentation calibration is performed semi annually. Create an SOP and implement instrument calibration.

6-2p

Is there a SOP for the collection and review of daily plant operating logs?

6-2a

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?

6-2d

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?

Comments:

Add stack O2 to log.

6-3d

Are boiler inspection reports for current year and past two years readily available?

Comments:

Inspection reports are current.

6-4d

Is there evidence that deficiencies listed in the boiler inspection reports or burner and interlock testing reports have been corrected?

Comments:

There is evidence that safety devices have been corrected.

6-5d

Is there evidence that emergency power system is regularly tested under load?

Comments:

Yes system is tested under load.

Category 7 - Physical Observations of Boiler Plant

How often do you visit the plant, walk around and visit with operators (all shifts)

Part

Yes

7-1

Are the steam safety valve vents discharged outside?

Comments:

7-2

Are water level gage glasses and sight flow indicators clean on boilers, de-aerator, condensate storage tank, blow-off tank and other equipment?

Comments:

7-3

Are boiler water level gage glasses and pressure gages easily visible from main floor in front of boilers?

Comments:

7-4

Are electrical and control cabinets closed and locked and all breakers properly labeled?

Comments:

Labeled but not locked. Boiler plant is secure

7-5

How is the overall cleanliness of the boiler plant?

Comments:

Boiler plant is clean.

7-6

Do the boiler plant operators work well together? (As a team)

Comments:

Category 8 - Facility Condition Assessment (FCA)

Part

Yes

8-1

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?)

Comments:

FCA 2021-No steam generation related Ds or Fs to note. An FCA was recently completed, but report has not been issued.

8-2

Are there construction projects identified for corrections (Major, Minor, NRM, Station Level) to identify these issues?

Comments:

No projects needed at this time.

Category 9 - Testing and Inspection

Are inspections and testing conducted in accordance with the following frequencies?

Part

Yes

9-0

Does your Qualified Professional Inspector (QPI) meet the minimum criteria?

Inspector is certified.

a. Key to Frequency Abbreviations

(1) H = Hourly.

(2) D = Daily.

(3) M = Once per month.

(4) 6M = Once every 6 months.

(5) Y = Once per year.

(6) 6Y = Once every 6 years.

9-1

(1) High pressure boilers (above 15 psig): Inspect furnace and other internal surfaces, closures and accessories. Y

Comments:

Internals performed on time.

9-2

(2) High pressure boilers (above 15 psig): Inspect exterior of Unit, casing, supports, closures, accessories, valves, controls. Y

Comments:

External inspections performed on time.

9-3

(3) Deaerator: Inspection and wet magnetic particle testing of welds of pressure vessel interior. 6Y

Comments:

NDT report for DA tank not available. DA NDT past due by 6 years.

9-4

(4) Boiler fouling and combustion gas flow check. Y

Comments:

Internal inspections performed.

9-5

(5) Tube leak check. Y

Comments:

Internal inspections performed.

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

(6) Low pressure boilers (15 psig and below): inspect interior and exterior, supports, closures, accessories, valves, and controls. Y

Comments:

9-7

(7) Deaerator: interior cleaning and visual inspection. Y

Comments:

Currently not performed.

9-8

(8) Adjust burner combustion settings and calibrate oxygen trim. 6M

Comments:

Combustion checks performed in house. Print outs for all points in the firing rate need to be kept for records.

9-9

(9) Check vibration of burner fans. 6M

Comments:

(10) Calibrate instrumentation, monitoring, and control systems. 6M

Comments:

Instrumentation is not calibrated semi annual.

9-11

(11) Calibrate pressure gages and thermometers. Y

Comments:

Gauge calibration has been performed in house.

(l2) Operational Testing of Boiler Safety Devices, such as:

9-12a

(a) Low-water cutoff (slow drain) M

Comments:

Performed on a monthly basis.

9-12b

(b) Fire each boiler and the pilot on the alternate fuel for 1 hour M

Comments:

Performed on a monthly basis.

9-12c

Comments:

Performed on a monthly basis.

9-12d

(d) Auxiliary low-water cut-off (slow drain) M

Comments:

Performed on a monthly basis.

9-12e

(e) Auxiliary low-water cut-off shunt switch M

Comments:

Performed on a monthly basis.

9-12f

(f) High-water alarm M

Comments:

Performed on a monthly basis.

9-12g

(g) Low-water alarm M

Comments:

Performed on a monthly basis.

9-12h

(h) High-steam pressure cut-out (recycle) 6M

Comments:

Performed semi annual.

9-12i

(i) High-steam pressure cut-out (non-recycle) 6M

Comments:

Performed semi annual.

9-12j

(j) Steam safety valves (raise boiler pressure until valve pops) 6M

Comments:

Performed semi annual.

9-12k

(k) Steam safety valves (accumulation test at high fire) Y

Comments:

Performed annual.

9-12l

(l) Flame scanner M

Comments:

Performed monthly.

9-12m

(m) Check gas vent for leaks 6M

Comments:

Performed semi annual.

9-12n

(n) High-gas fuel pressure cut-off 6M

Comments:

Performed semi annual.

(o) Low-gas fuel pressure cut-off 6M

Comments:

Performed semi annual.

(p) Gas fuel safety shut off valves proof of closure 6M

Comments:

Performed semi annual.

9-12q

(q) Leak test gas fuel safety shut off valves 6M

Comments:

Performed semi annual.

9-12r

(r) High-fuel oil temperature cut-off (heated fuel) 6M

Comments:

N/A

9-12s

(s) Low-fuel oil temperature cut-off (heated fuel) 6M

Comments:

N/A

9-12t

(t) Low-atomizing pressure for fuel oil 6M

Comments:

Performed semi annual.

9-12u

(u) High-fuel oil pressure cut-off 6M

Comments:

Performed semi annual.

9-12v

(v) Low-fuel oil pressure cut-off 6M

Comments:

Performed semi annual.

9-12w

(w) Fuel oil safety shut off valves proof of closure 6M

Comments:

Performed semi annual.

9-12x

(x) Leak test fuel oil safety shut off valves 6M

Comments:

Performed semi annual.

9-12y

(y) Check operation of Liquid Petroleum Gas pilot 6M

Comments:

Performed semi annual.

9-12z

(z) Low-pilot gas pressure cut-out 6M

Comments:

Performed semi annual.

9-12aa

(aa) Forced draft fan motor interlock 6M

Comments:

Performed semi annual.

9-12bb

(bb) Forced draft fan damper wide open for purge 6M

Comments:

Performed semi annual.

9-12cc

(cc) Boiler outlet damper wide open for purge 6M

Comments:

Performed semi annual.

9-12dd

(dd) Purge air flow interlock 6M

Comments:

Performed semi annual.

9-12ee

(ee) Timing for pre-purge 6M

Comments:

Performed semi annual.

9-12ff

(ff) Timing for post-purge 6M

Comments:

Performed semi annual.

9-12gg

(gg) Igniter timing 6M

Comments:

Performed semi annual.

9-12hh

(hh) Low fire position interlock 6M

Comments:

Performed semi annual.

9-12ii

(ii) Combustion air interlock 6M

Comments:

Performed semi annual.

(jj) Main flame out; i.e., time to close valves 6M

Comments:

Performed semi annual.

9-12kk

(kk) Ignition flame out; i.e., it is time to close valves 6M

Comments:

Performed semi annual.

9-12ll

(ll) Minimum igniter flame test 6M

Comments:

Performed semi annual.

9-12mm

(mm) Scanner not sensing ignition spark 6M

Comments:

Performed semi annual.

9-12nn

(nn) Low-oxygen alarm and/or cut-out 6M

Comments:

Performed semi annual.

9-12oo

(oo) Pre-purge setting of flue gas recirculation damper 6M

Comments:

Performed semi annual.

9-12pp

(pp) Interlock of building outside air damper with burner control 6M

Comments:

Performed semi annual.

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) Overall plant operation H

Comments:

Performed hourly

9-13b

(b) Blowdown water columns D

Comments:

9-13c

Comments:

9-13d

(d) Check furnace pressure 6M

Comments:

P259:U261P259:AE261P259:AG261J257P259:S261P259:AH26P259:AI281

9-13e

(e) Check combustion gas leaks into boiler room 6M

Comments:

Performed semi annually.

9-13f

(f) Clean waterside of boilers Y

Comments:

Internal inspections performed.

9-13g

(g) Clean fireside and repair refractory Y

Comments:

Internal inspections performed.

9-13h

(h) Operation of deaerator high and low water alarms 6M

Comments:

Performed monthly.

9-13i

(i) Operation of deaerator steam pressure or temperature control 6M

Comments:

9-13j

(j) Operation of condensate storage tank high and low water alarms 6M

Comments:

Performed monthly.

9-13k

(k) Operation of all other alarm devices M

Comments:

9-13l

(k) Operation of boiler economizers; temperatures in or out H

Comments:

9-13m

(m) Review written procedures Y

Comments:

Procedures have been reviewed.

9-14p

Is there a SOP for annual and semi-annual safety testing on each boiler?

9-14a

Is testing being conducted properly and in accordance with the directive / policies?

9-14d

Is the documentation of the annual and semi-annual being done properly and are several years of data on file?

Comments:

Semi annual testing is performed comnpletely in house. In house testing capability is highly regarded and that skillset must be maintained, however Directive 1810 does require a contractor be retained to perform at least one round of semi annual testing.

Category 10 - Layup and Rotation

Part

Yes

10-1p

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?

A written rotation plan for the boilers is not in place.

10-1a

Is there evidence that the equipment is being rotated on a fixed schedule?

Equipment is rotated fixed schedule. Monthly

10-1d

Is there two years of equipment rotation documentation?

10-2p	P	E	S	C	O	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
						Boiler Layup SOP in place.
10-2a	A	E	S	C	O	Has this facility ever put a boiler into layup?

10-2d D E S C O Is there documentation of past boiler layup?

	Additional Items:
A-1	No official cast iron survey has been performed.	X
A-2	No official A307 bolt survey has been performed.	X
A-3	DA Non destructive testing is over due by five years. This inspection must be performed as soon as possible.	X
A-4	Update safety device testing documentation sheets to the current 8th edition.	X
A-5	Update steam recycle limt switch on all boilers to non recycle switch to comply with Directive 1810 and SDTM 8th Edition.	X
A-6	Add SLAMPS switch to all boilers to comply with SDTM 8th Edition.	X
A-7	Replace cast iron steam safety relief valves with cast steel bodied models to comply with SDTM 8th Edition.	X
A-8	Relocate boiler fan current relays from high voltage panel to isolated panel not containing any exposed high voltage (>120v).	X
A-9	Replace economizer liquid relief valves with LRVEs with a stamnped set point below MAWP of the economizer.	X
A-10	Add High Propane Pressure alarm to main propane line.	X
A-11		X
A-12		X

Directive Score

Progress Procedure Action Documentation 0.6875 0.875 0.61111111111111116 Goal Procedure Action Documentation 0.3125 0.125 0.38888888888888884

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

Management Score

Progress Procedure Action Documentation 1 1 1 Goal Procedure Action Documentation 0 0 0

Training Score Progress Procedure Action Documentation 1 1 1 Goal Procedure Action Documentation 0 0 0

Parts & Supplies Score Progress Procedure Action Documentation 0 1 0.33333333333333331 Goal Procedure Action Documentation 1 0 0.66666666666666674

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

Records Score Progress Procedure Action Documentation 0.5 0.75 0.9 Goal Procedure Action Documentation 0.5 0.25 9.9999999999999978E-2

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

Facility Condition Assessment Score Progress Procedure Action Documentation 0 1 0 Goal Procedure Action Documentation 0

Testing & Inspection Score Progress Procedure Action Documentation 1 0.9375 1 Goal Procedure Action Documentation 0 6.25E-2 0

Overall Hospital Score Progress Procedure Action Documentation 0.6428571428571429 0.94210526315789478 0.78333333333333333 Goal Procedure Action Documentation 0.3571428571428571 5.7894736842105221E-2 0.21666666666666667

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Aug 13, 2025.