Attachment 2 - VA Corrective Preventative Maintenance Form.pdf

Revision 2.1 1 of 2 Serial #:

Corrective and Preventive Maintenance Checklist for Ceiling Mounted Patient Lifts The commissioning for a patient ceiling lift system(s) shall include, but not be limited to, the following points as components of the commissioning procedures.

NOTE: Ceiling mounted patient lifts are not to be installed in treatment units with actively suicidal patients.

Facility: Work Order: Manufacturer:

Lift Location: Model:

VAMC Contact: Serial Number: EE Number:

VAMC Contact's Phone Number: Mfgr Contact:

Installer: Mfgr Contact's Phone Number:

Installer's Phone Number: Date:

Structure Complete

Perform a visual inspection to verify proper connections of the lift's structural system to the building’s structure (including seismic bracing if applicable).

Perform a visual inspection to verify proper interface at the ceiling (hard deck or soft tile) and proper installation of all protective features around the support rods and rails/tracks.

Perform a visual inspection to verify structural component sizing and physical installation to ensure that the correct structural system is in place and properly installed to support the lift.

NOTES:

Rails/Tracks and End Stops PASS FAIL

1 Verification that all fasteners and set screws are properly tightened on the trollies and rails/tracks.

Ensure that the rail/track is free of gaps (unless required by design). If included in installation, verify rail turntable function, exchanger function, gate alignment, and safety block installation.

Confirm track is clean and clear of all debris. (Use manufacturer’s recommended cleaning materials to avoid damage to the motor case and other components.)

4 Verification that all manufacturer specified end stops or docking gates are properly installed.

Lift Unit and Straps PASS FAIL

1 Inspection of lift unit casing for cracks and alignment.

2 Verification that the lift unit charges properly.

Inspection and activation of hand control for full operation (e.g., up, down, left, right) and “return to charge” function if applicable.

Confirm any and all lift unit indicator lights are functioning. (e.g., red service warning light, charging state light)

5 Inspection and verification of all emergency functions of the lift unit.

6 Full extension and inspection of lift strap for loose threads or frays.

7 Inspection of spreader bar and clips for cracks and for loose or missing rings or cotter pins.

Revision 2.1 2 of 2 Serial #:

Load Testing PASS FAIL

Verification of any “soft start” or “soft stop” features and that lifting speed does not exceed 2.5 inches per second with “zero” load.

Verification of load testing and deflection testing at the manufacturer's specified maximum rated lift capacity.

Verification of any “soft start” and “soft stop” features and that lifting speed does not exceed 1.5 inches per second under maximum rated lift capacity.

4 Verification of function of emergency stop at maximum rated lift capacity.

5 Verification of emergency lowering feature at maximum rated lift capacity.

Inspector COMPLETE

After the activities listed in the above checklist and in the manufacturer's installation/operations/owner’s manual(s) have been completed, the inspector shall release the ceiling mounted lift installation to VA representative.

SIGNATURE: DATE:

TITLE: President

VA Representative COMPLETE

After the activities listed in the above checklist and in the manufacturer's installation/operations/owner’s manual(s) have been completed, the VA representative shall review those items with the inspector prior to releasing the ceiling mounted lift back into service to ensure completion of all requirements.

TITLE:

Manager of the Service Using the Ceiling Mounted Lifts COMPLETE

After the activities listed in the above checklist and in the manufacturer's installation/operations/owner’s manual(s) have been completed, the manager of the service using the ceiling mounted lifts confirms that the current staff have received initial training on ceiling mounted lifts and that there is a process in place to provide ongoing training on the proper use of ceiling mounted lifts.

TITLE: