*JO: Prepublication Standards – Revised Requirements for the Environment of Care (EC) Chapter[®] [REF: CMS, EOC] TJC Pre-Pub Standards, March 3, 2014 JCo1403_B7 CMS Survey and Certification letter 1407 clarified when a hospital may adjust its maintenance, inspection, and testing activities for facility and medical equipment from what is recommended by the manufacturer. In response/concert with this, TJC has added: EC.02.04.03, EP24 (for radiologic and new medical equipment) and EC.02.05.05, EP6 (for utility systems). Both are new 2014 elements of performance (EPs) for deemed-status hospitals. Both require inspection, testing and maintenance in accordance with manufacturer’s recommendations whenever there is insufficient maintenance history to support the use of alternative maintenance approaches. [Key Def] Maintenance history is defined as including: • records of the hospital’s experience with the equipment/system over time • relevant records from servicing contractors and • “Information made public by nationally recognized sources”. Tip: If utility system maintenance is performed by an external service provider, their documentation may suffice, but you must have timely access to it “during survey and as needed”.
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