Q: In regards to medical gas system testing, our local AHJ uses NFPA 99-2015 edition. My corporate office has stated that there are no PM’s that have to be done. I feel this is not only incorrect but just not a safe practice. Our medical air compressor and vacuum system are placed in the high-risk category due to the impact to patients and their lives. Where does the NFPA 99 reference and give the codes for the testing and inspection frequencies of the equipment?
A: Section 184.108.40.206.1 of NFPA 99-2015 says health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.
Section 220.127.116.11.2.2 says scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
Annex section A.18.104.22.168.2.2 says in addition to the minimum inspection and testing in 5.1.14, facilities should consider annually inspecting equipment and procedures and correcting any deficiencies.
(Words in bold text my doing…)
So, section 22.214.171.124.1 says you must have a periodic maintenance program. Section A.126.96.36.199.2 says you should consider an annual program. The AHJ is correct in requiring you to perform an annual inspection of the medical gas system, since section 188.8.131.52.2. gives him that authority. Even if the AHJ did not require annual PMs, you would have had to conduct a risk assessment to determine the frequency of the PMs. Any deviations from an annual frequency would have to be explained in the risk assessment.
You should consider yourself lucky… CMS Appendix Q says failure to maintain any feature of life safety should result in an Immediate Jeopardy decision. If your surveyor did not consider this an Immediate Jeopardy situation, then you dodged a bullet.