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Piped Medical Gas/Vacuum Systems - Maintenance Strategy

What is the requirement for activities and intervals of testing for piped medical gas and vacuum systems?

Any examples are for illustrative purposes only. 

The Joint Commission standards are not prescriptive regarding testing frequencies for piped medical gas and vacuum systems. The facility may determine its testing frequency by policy and the surveyor will evaluate testing based on that policy. 

In accordance with EC.02.05.09, for each piped medical gas and vacuum system, the source, distribution, inlets/outlets, and the alarms that protect the systems are to be maintained in a safe and reliable condition. 

The organization is required by EC.02.05.01 to develop a maintenance strategy based upon either manufacturer's recommendations or an alternative equipment maintenance (AEM) strategy. Piped medical gas and vacuum systems are considered high-risk utility systems. 

Issues such as system complexity, system age/condition, patient acuity, etc. are to be used to assess maintenance strategies. NFPA 99-2012 Appendix B can be used as a guide for establishing a maintenance strategy, but appendix material are not requirements unless adopted by a controlling authority. The survey process will evaluate the maintenance strategy assessment process for effectiveness and validate that it has been properly implemented.
Last updated on March 19, 2021
Manual: Ambulatory
Chapter: Environment of Care EC

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