TJC Requirements for Testing and Maintaining Non-high-risk Utility Systems

PUBLISHED: Feb 28, 2017

Joint Commission Standard EC.02.05.05 requires hospitals to “…inspect, test and maintain utility systems.” Element of Performance 6 for this standard specifies that the hospital must inspect, test and maintain the non-high-risk utility system components that are included on the organizations’ utility systems inventory. Additionally:

  • Documentation of the inspection, testing and/or maintenance must include the completion date and results.
  • If maintenance is completed by an outside service, the hospital does not need to have the maintenance documentation in their possession but does need to be able to access the documentation during surveys and at other times as needed.
  • Scheduled maintenance activities for non-high-risk utility systems components that are a part of an alternative equipment maintenance (AEM) program inventory must be completed with 100% frequency. Note: this is a change – formally it was “not less than 90%” completion rate.

Included with today’s notice are example policies related to this TJC requirement.

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