Audit

EC.02.05.01 The hospital manages risks associated with its utility systems.

EP1 - The hospital designs and installs utility systems according to National Fire Protection Association codes to meet patient care and operational needs.

EP2 - Building systems are designed to meet the National Fire Protection Association’s Categories 1–4 requirements.
(For full text, refer to NFPA 99-2012: Chapter 4 for descriptions of the four categories related to gas, vacuum, electrical, and electrical equipment.)

EP3 - For hospitals that do not use Joint Commission accreditation for deemed status purposes: The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems). The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains a written inventory of all operating components of utility systems.

EP4 - The hospital identifies high-risk operating components of utility systems on the inventory for which there is a risk of serious harm or death to a patient or staff member should the component fail.
Note: High-risk utility system components include life-support equipment.

EP5 - The hospital identifies the activities and associated frequencies, in writing, for inspecting, testing, and maintaining all operating components of utility systems on the inventory. These activities and associated frequencies are in accordance with manufacturers’ recommendations or with strategies of an alternative equipment maintenance (AEM) program.
Note 1: The strategies of an AEM program must not reduce the safety of equipment and must be based on accepted standards of practice. *
Note 2: For guidance on maintenance and testing activities for Essential Electric Systems (Type I), see NFPA 99-2012: 6.4.4.
Footnote *: An example of guidelines for physical plant equipment maintenance is the American Society for Healthcare Engineering (ASHE) book Maintenance Management for Health Care Facilities.

EP6 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s activities and frequencies for inspecting, testing, and maintaining the following items must be in accordance with manufacturers’ recommendations:
- Equipment subject to federal or state law or Medicare Conditions of Participation in which inspecting, testing, and maintaining be in accordance with the manufacturers’ recommendations, or otherwise establishes more stringent maintenance requirements
- New operating components with insufficient maintenance history to support the use of alternative maintenance strategies
Note: Maintenance history includes any of the following documented evidence:
- Records provided by the hospital’s contractors
- Information made public by nationally recognized sources
- Records of the hospital’s experience over time

EP7 - For hospitals that use Joint Commission accreditation for deemed status purposes: A qualified individual(s) uses written criteria to support the determination of whether it is safe to permit operating components of utility systems to be maintained in an alternate manner that includes the following:
- How the equipment is used, including the seriousness and prevalence of harm during normal use
- Likely consequences of equipment failure or malfunction, including seriousness of and prevalence of harm
- Availability of alternative or backup equipment in the event the equipment fails or malfunctions
- Incident history of identical or similar equipment
- Maintenance requirements of the equipment
(For more information on defining staff qualifications, refer to Standard HR.01.02.01)

EP8 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital identifies operating components of utility systems on its inventory that are included in an alternative equipment maintenance program.

EP9 - The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.
Note 1: Examples of utility system controls that should be labeled are utility source valves, utility system main switches and valves, and individual circuits in an electrical distribution panel.
Note 2: For example, the fire alarm system’s circuit is clearly labeled as Fire Alarm Circuit; the disconnect method (that is, the circuit breaker) is marked in red; and access is restricted to authorized personnel. Information regarding the dedicated branch circuit for the fire alarm panel is located in the control unit. For additional guidance, see NFPA 101-2012: 18/19.3.4.1; 9.6.1.3; NFPA 72-2010: 10.5.5.2.

EP10 - The hospital has written procedures for responding to utility system disruptions.

EP11 - The hospital's procedures address shutting off the malfunctioning system and notifying staff in affected areas.

EP12 - The hospital's procedures address performing emergency clinical interventions during utility system disruptions.

EP13 - The hospital responds to utility system disruptions as described in its procedures.

EP14 - The hospital minimizes pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems.

EP15 - In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity.
Note: For more information about areas designed for control of airborne contaminants, the basis for design compliance is the Guidelines for Design and Construction of Health Care Facilities, based on the edition used at the time of design (if available).

EP16 - In non–critical care areas, the ventilation system provides required pressure relationships, temperature, and humidity.
Note: Examples of non–critical care areas are general care nursing units; clean and soiled utility rooms in acute care areas; laboratories, pharmacies, diagnostic and treatment areas, food preparation areas, and other support departments.

EP17 - The hospital maps the distribution of its utility systems.

EP18 - Medical gas storage rooms and transfer and manifold rooms comply with NFPA 99-2012: 9.3.7.

EP19 - The emergency power supply system’s equipment and environment are maintained per manufacturers’ recommendations, including ambient temperature not less than 40°F; ventilation supply and exhaust; and water jacket temperature (when required). (For full text, refer to NFPA 99-2012: 9.3.10)

EP20 - Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment authorized by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. (For full text, refer to NFPA 99-2012: 6.3.2.2.8.4; 6.3.2.2.8.7; 6.4.4.2)

EP21 - Electrical distribution in the hospital is based on the following categories:
- Category 1: Critical care rooms served by a Type 1 essential electrical system (EES) in which electrical system failure is likely to cause major injury or death to patients, including all rooms where electric life support equipment is required.
- Category 2: General care rooms served by a Type 1 or Type 2 EES in which electrical system failure is likely to cause minor injury to patients.
- Category 3: Basic care rooms in which electrical system failure is not likely to cause injury to patients. Patient care rooms are required to have a Type 3 EES where the life safety branch has an alternate source of power that will be effective for 1 1/2 hours.
(For full text, refer to NFPA 99-2012: 3.3.138; 6.3.2.2.10; 6.6.2.2.2; 6.6.3.1.1)

EP22 - Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered are tested after initial installation, replacement, or servicing. In pediatric locations, receptacles in patient rooms (other than nurseries), bathrooms, play rooms, and activity rooms are listed tamper-resistant or have a listed cover. Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking. (For full text, refer to NFPA 99-2012: 6.3.2; 6.3.3; 6.3.4; 6.4.2.2.6; 6.5.2.2.4.2; 6.6.2.2.3.2)

EP23 - Power strips in a patient care vicinity are only used for components of movable electrical equipment used for patient care that have been assembled by qualified personnel. These power strips meet UL 1363A or UL 60601-1. Power strips used outside of a patient care vicinity, but within the patient care room, meet UL 1363. In non–patient care rooms, power strips meet other UL standards. (For full text, refer to NFPA 99-2012: 10.2.3.6; 10.2.4; NFPA 70-2011: 400-8; 590.3(D); Tentative Interim Amendment (TIA) 12-5)

EP24 - Extension cords are not used as a substitute for fixed wiring in a building. Extension cords used temporarily are removed immediately upon completion of the intended purpose. (For full text, refer to NFPA 99-2012: 10.2.3.6; 10.2.4; NFPA 70-2011: 400-8; 590.3(D); Tentative Interim Amendment (TIA) 12-5)

EP25 - Areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum are in accordance with NFPA 101-2012: 8.7 and NFPA 99-2012 as follows:
- Zone valves are located immediately outside each anesthetizing location for medical gas or vacuum, readily accessible in an emergency, and arranged so shutting off any one anesthetizing location will not affect others.
- Area alarm panels are installed to monitor all medical gas, medical-surgical vacuum, and piped waste anesthetic gas disposal (WAGD) systems. Alarm panels include visual and audible sensors and are in locations that provide for surveillance, including medical gas pressure decreases of 20% and vacuum decreases of 12-inch gauge HgV (mercury vacuum).
- Alarm sensors are installed either on the source side of individual room zone valve box assemblies or on the patient/use side of each of the individual zone valve box assemblies. (For full text, refer to NFPA 101-2012: 18/19.3.2.3; NFPA 99-2012: 5.1.4.8.7; 5.1.9.3)

EP26 - Areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum are in accordance with NFPA 101-2012: 8.7 and NFPA 99-2012 as follows: The essential electrical system’s (EES) critical branch supplies power for task illumination, fixed equipment, select receptacles, and select power circuits. The EES equipment system supplies power to the ventilation system. (For full text, refer to NFPA 101-2012: 18/19.3.2.3; NFPA 99-2012: 6.4.2.2.4.2)

EC.02.05.03 The hospital has a reliable emergency electrical power source.

EP1 - For facilities that were constructed, or had a change in occupancy type, or have undergone an electrical system upgrade since 1983, the hospital has a Type 1 or Type 3 essential electrical system in accordance with NFPA 99, 2012 edition. This essential electrical system must be divided into three branches, including the life safety branch, critical branch, and equipment branch. Both the life safety branch and the critical branch are kept independent of all other wiring and equipment, and they transfer within 10 seconds of electrical interruption. Each branch has at least one automatic transfer switch. For additional guidance, see NFPA 99-2012: 6.4.2.2.

EP2 - The hospital provides emergency power within 10 seconds for the following: Alarm systems, as required by the Life Safety Code.
Note: For guidance in establishing a reliable emergency power system (that is, an essential electrical distribution system), see NFPA 99-2012: 6.4.1.1; 6.4.2.2; NFPA 110-2010: 4.1; Table 4.1(b).

EP3 - The hospital provides emergency power within 10 seconds for the following: Exit route and exit sign illumination, as required by the Life Safety Code.
Note: For guidance in establishing a reliable emergency system (that is, an essential electrical distribution system), see NFPA 99-2012: 6.4.1.1; 6.4.2.2; NFPA 110-2010: 4.1; Table 4.1(b).

EP4 - New buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the life safety branch of the electrical system described in NFPA 99. (For full text, refer to NFPA 101-2012: 18.2.9.2; 18.2.10.5; NFPA 99-2012: 6.4.2.2)

EP5 - The hospital provides emergency power within 10 seconds for the following: Emergency communication systems, as required by the Life Safety Code.
Note: For guidance in establishing a reliable emergency power system (that is, an essential electrical distribution system), see NFPA 99-2012: 6.4.2.2; NFPA 110-2010: 4.1; Table 4.1(b).

EP6 - The hospital provides emergency power within 10 seconds for the following: Equipment that could cause patient harm when it fails, including life-support systems; blood, bone, and tissue storage systems; medical air compressors; and medical and surgical vacuum systems.
Note: For guidance in establishing a reliable emergency power system (that is, an essential electrical distribution system), see NFPA 99-2012: 6.4.1.1; 6.4.2.2; NFPA 110-2010: 4.1; Table 4.1(b).

EP7 - The hospital provides emergency power within 10 seconds for the following: Areas in which loss of power could result in patient harm, including intensive care, emergency rooms, operating rooms, recovery rooms, obstetrical delivery rooms, and nurseries.
Note: For guidance in establishing a reliable emergency power system (that is, an essential electrical distribution system), see NFPA 99-2012: 6.4.1.1; 6.4.2; NFPA 110-2010: 4.1; Table 4.1(b).

EP11 - The hospital provides emergency power within 10 seconds for the following: Emergency lighting at emergency generator locations. The hospital’s emergency power system (EPS) has a remote manual stop station (with identifying label) to prevent inadvertent or unintentional operation. A remote annunciator (powered by storage battery) is located outside the EPS location.
Note: For guidance in establishing a reliable emergency power system (that is, an essential electrical distribution system), refer to NFPA 99-2012: 6.4.1.1.6; 6.4.1.1.17; 6.4.2.2; NFPA 110-2010: 5.6.5.6; 7.3.1.

EP12 - Equipment designated to be powered by emergency power supply is energized by the hospital’s design. Staging of equipment startup is permissible. (For full text, refer to NFPA 99-2012: 6.4.2.2)

EP13 - The hospital provides emergency power for elevators selected to provide service to patients during interruption of normal power (at least one for nonambulatory patients).
Note: For guidance in establishing a reliable emergency power system for the equipment branch (that is, an essential electrical distribution system), refer to NFPA 99-2012: 6.4.2.2.

EP14 - The hospital implements a policy to provide emergency backup for essential medication dispensing equipment identified by the hospital, such as automatic dispensing cabinets, medication carousels, and central medication robots.Note: Examples of emergency backup can include emergency power, battery-based indoor generators, or other actions describing how dispensing and administration of medications will continue when emergency backup is needed.

EP15 - The hospital implements a policy to provide emergency backup for essential refrigeration for medications identified by the hospital, such as designated refrigerators and freezers.
Note: Examples of emergency backup can include emergency power, battery-based indoor generators, or other actions describing how refrigeration of medications will continue when emergency backup is needed.

EP16 - For hospitals that use Joint Commission accreditation for deemed status purposes: Battery lamps and flashlights are available in areas not serviced by the emergency supply source.

EC.02.05.05 The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.

EP1 - When performing repairs or maintenance activities, the hospital has a process to manage risks associated with air-quality requirements; infection control; utility requirements; noise, odor, dust, vibration; and other hazards that affect care, treatment, or services for patients, staff, and visitors.

EP2 - For hospitals that do not use Joint Commission accreditation for deemed status purposes: The hospital tests utility system components on the inventory before initial use. The completion dates and test results are documented.
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital tests utility system components on the inventory before initial use and after major repairs or upgrades. The completion date and the results of the tests are documented.

EP4 - The hospital inspects, tests, and maintains the following: High-risk utility system components on the inventory. The completion date and the results of the activities are documented.
Note 1: A high-risk utility system includes components for which there is a risk of serious injury or even death to a patient or staff member should it fail, which includes life-support equipment.
Note 2: Required activities and associated frequencies for maintaining, inspecting, and testing of utility systems components completed in accordance with manufacturers’ recommendations must have a 100% completion rate.
Note 3: Scheduled maintenance activities for high-risk utility systems components in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate.

EP5 - The hospital inspects, tests, and maintains the following: Infection control utility system components on the inventory. The completion date and the results of the activities are documented.
Note 1: Required activities and associated frequencies for maintaining, inspecting, and testing of utility systems components completed in accordance with manufacturers’ recommendations must have a 100% completion rate.
Note 2: Scheduled maintenance activities for infection control utility systems components in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate.

EP6 - The hospital inspects, tests, and maintains the following: Non-high-risk utility system components on the inventory. The completion date and the results of the activities are documented.
Note: Scheduled maintenance activities for non-high-risk utility systems components in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate. AEM frequency is determined by the hospital AEM program.

EP7 - Line isolation monitors (LIM), if installed, are tested at least monthly by actuating the LIM test switch per NFPA 99-2012: 6.3.2.6.3.6, which activates both visual and audible alarms. For LIM circuits with automated self-testing, a manual test is performed at least annually. LIM circuits are tested per NFPA 99-2012: 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. (For full text, refer to NFPA 99-2012: 6.3.2; 6.3.3; 6.3.4)

EP8 - The hospital meets NFPA 99-2012: Health Care Facilities Code requirements related to electrical systems and heating, ventilation, and air conditioning (HVAC). (For full text, refer to NFPA 99-2012: Chapters 6 and 9)
Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital meets the applicable provisions of the Health Care Facilities Code Tentative Interim Amendments (TIAs) 12-2 and 12-3.

EC.02.05.07 The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.

Rational: Emergency electrical power supply systems may fail during a power disruption, leaving the hospital unable to deliver safe care, treatment, and services to patients. Testing these systems for sufficient lengths of time at regular frequencies increases the likelihood of detection reliability problems and reduces the risk of loosing this critical resource when it is most needed.

EP1 - At least monthly, the hospital performs a functional test of emergency lighting systems and exit signs required for egress and task lighting for a minimum duration of 30 seconds, along with a visual inspection of other exit signs. The test results and completion dates are documented. (For full text, refer to NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-2012: 6.3.2.2.11.5)

EP2 - Every 12 months, the hospital performs a functional test of battery-powered lights on the inventory required for egress and exit signs for a duration of 1 1/2 hours. For new construction, renovation, or modernization, battery-powered lighting in locations where deep sedation and general anesthesia are administered is tested annually for 30 minutes. The test results and completion dates are documented. (See also LS.02.01.20, EP 39) (For full text, refer to NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-2012: 6.3.2.2.11.5)

EP3 - The hospital performs a functional test of Level 1 stored emergency power supply systems (SEPSS) on a monthly basis and performs a test of Level 2 SEPSS on a quarterly basis. Test duration is for five minutes or as specified for its class (whichever is less). The hospital performs an annual test at full load for 60% of the full duration of its class. The test results and completion dates are documented.
Note 1: Non–SEPSS battery backup emergency power systems that the hospital has determined to be critical for operations during a power failure (for example, laboratory equipment or electronic medical records) should be properly tested and maintained in accordance with manufacturers' recommendations.
Note 2: Level 1 SEPSS are intended to automatically supply illumination or power to critical areas and equipment essential for safety to human life. Included are systems that supply emergency power for such functions as illumination for safe exiting, ventilation where it is essential to maintain life, fire detection and alarm systems, public safety communications systems, and processes where the current interruption would produce serious life safety or health hazards to patients, the public, or staff.
Note 3: Class defines the minimum time for which the SEPSS is designed to operate at its rated load without being recharged. For additional guidance, see NFPA 111-2010: 8.4.

EP4 - At least weekly, the hospital inspects the emergency power supply system (EPSS), including all associated components and batteries. The results and completion dates of weekly inspections are documented. (For full text, refer to NFPA 110-2010: 8.3.1; 8.3.3; 8.3.4; 8.4.1)

EP5 - At least monthly, the hospital tests each emergency generator beginning with a cold start under load for at least 30 continuous minutes. The cooldown period is not part of the 30 continuous minutes. The test results and completion dates are documented. (For full text, refer to NFPA 99-2012: 6.4.4.1)

EP6 - The monthly tests for diesel-powered emergency generators are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator or meets the manufacturer’s recommended prime movers’ exhaust gas temperature. If the hospital does not meet either the 30% of nameplate rating or the recommended exhaust gas temperature during any test in EC.02.05.07, EP 5, then it must test the emergency generator once every 12 months using supplemental (dynamic or static) loads of 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes, for a total of 1½ continuous hours. (For full text, refer to NFPA 99-2012: 6.4.4.1)
Note: Tests for non-diesel-powered generators need only be conducted with available load.

EP7 - At least monthly, the hospital tests all automatic and manual transfer switches on the inventory. The test results and completion dates are documented. (For full text, refer to NFPA 99-2012: 6.4.4.1)

EP8 - At least annually, the hospital tests the fuel quality to ASTM standards. The test results and completion dates are documented.
Note: For additional guidance, see NFPA 110-2010: 8.3.8.

EP9 - At least once every 36 months, hospitals with a generator providing emergency power test each emergency generator for a minimum of 4 continuous hours. The test results and completion dates are documented.
Note: For additional guidance, see NFPA 110-2010, Chapter 8.

EP10 - The 36-month diesel-powered emergency generator test uses a dynamic or static load that is at least 30% of the nameplate rating of the generator or meets the manufacturer’s recommended prime movers' exhaust gas temperature.
Note 1: Tests for non-diesel-powered generators need only be conducted with available load.
Note 2: For additional guidance, see NFPA 110-2010, Chapter 8.

EC.02.05.09 The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.

EP1 - Medical gas, medical air, surgical vacuum, waste anesthetic gas disposal (WAGD), and air supply systems in which failure is likely to cause major injury or death are designated as follows:
- Category 1: Systems in which failure is likely to cause minor injury to patients
- Category 2: Systems in which failure is not likely to cause injury, but can cause discomfort to patients
- Category 3: Deep sedation and general anesthesia are not administered when using Category 3 medical gas system
(For full text, refer to NFPA 99-2012: 5.1.1.1; 5.2.1; 5.3.1.1; 5.3.1.5; 5.1.14.2)

EP2 - All master, area, and local alarm systems used for medical gas and vacuum systems comply with the category 1–3 warning system requirements. (For full text, refer to NFPA 99-2012: 5.1.9; 5.2.9; 5.3.6.2.2)

EP3 - Containers, cylinders, and tanks are designed, fabricated, tested, and marked in accordance with NFPA 99-2012: 5.1.3.1.1–5.1.3.1.7.

EP4 - Locations containing only oxygen or medical air have doors labeled "Medical Gases: NO Smoking or Open Flame." Locations containing other gases have doors labeled “Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.”

EP5 - A precautionary sign readable from 5 feet away is on each door or gate of a cylinder storage room, where the sign, at a minimum, includes the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN. NO SMOKING.” Storage is planned so cylinders are used in the order they are received from the supplier. Only gas cylinders and reusable shipping containers and their accessories are permitted to be stored in rooms containing central supply systems or gas cylinders.

EP6 - When the hospital uses cylinders with an integral pressure gauge, a threshold pressure considered empty is established when the volume of stored gases is as follows:
- When more than 300 but less than 3,000 cubic feet, the storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited-combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2-hour fire protection rating.
- When less than 301 cubic feet in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in NFPA 99-2012: 11.6.2.(For full text, refer to NFPA 99-2012: 5.1.3.1; 5.1.3.2.3; 5.2.3.1; 5.3.10; 11.3; 11.6.5.2.1)

EP7 - In time frames defined by the hospital, the hospital inspects, tests, and maintains critical components of piped medical gas and vacuum systems, waste anesthetic gas disposal (WAGD), and support gas systems on the inventory. This inventory of critical components includes at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and inlets and outlets. Activities, dates, and results are documented. Persons maintaining the systems are qualified by training and certification to the requirements of the American Society of Sanitary Engineers (ASSE) 6030 or 6040. (For full text, refer to NFPA 99-2012: 5.1.14.2; 5.1.15; 5.2.14; 5.3.13)

EP8 - When the hospital has bulk oxygen systems above ground, they are in a locked enclosure (such as a fence) at least 10 feet from vehicles and sidewalks. There is permanent signage stating “OXYGEN – NO SMOKING – NO OPEN FLAMES.” Note: For additional guidance, refer to NFPA 99-2012: 5.1.3.5.12.

EP9 - The hospital’s emergency oxygen supply connection is installed in a manner that allows a temporary auxiliary source to connect to it.
Note: For additional guidance, refer to NFPA 99-2012: 5.1.3.5.13.

EP10 - The hospital tests piped medical gas and vacuum systems for purity, correct gas, and proper pressure when these systems are installed, modified, or repaired. The test results and completion dates are documented. (For full text, refer to NFPA 99-2012: 5.1.2; 5.1.4; 5.1.14.4.1; 5.1.14.4.6; 5.2.13)

EP11 - The hospital makes main supply valves and area shutoff valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control. Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (see NFPA 99-2012: Table 5.1.11), and operating pressure if other than standard. Labels are at intervals of 20 feet or less and are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. (For full text, refer to NFPA 99-2012: 5.1.4; 5.1.11.1; 5.1.11.2; 5.1.14.3; 5.2.11; 5.3.13.3; 5.3.11)

EP12 - The hospital implements a policy on all cylinders within the hospital that includes the following:
- Labeling, handling, and transporting (for example, in carts, attached to equipment, on racks) in accordance with NFPA 99-2012: 11.5.3.1 and 11.6.2
- Physically segregating full and empty cylinders from each other in order to assist staff in selecting the proper cylinder
- Adaptors or conversion fittings are prohibited
- Oxygen cylinders, containers, and associated equipment are protected from contamination, damage, and contact with oil and grease
- Cylinders are kept away from heat and flammable materials and do not exceed a temperature of 130°F
- Nitrous oxide and carbon dioxide cylinders do not reach temperatures lower than manufacturer recommendations or -20°F- Valve protection caps (if supplied) are secured in place when cylinder is not in use
- Labeling empty cylinders
- Prohibiting transfilling in any compartment with patient care
(For full text, refer to NFPA 99-2012: 11.6.1; 11.6.2; 11.6.5; 11.7.3)

EP13 - At no time is transfilling done in any patient care room. A designated area is used away from any section of the hospital where patients are housed, treated, or examined. The designated area is separated by a barrier of at least 1-hour fire-resistant construction from any patient care areas. Transfilling cylinders is only of the same gas (no mixing of different compressed gases). Transfilling of liquid oxygen is only done in an area that is mechanically ventilated, sprinklered, and has ceramic or concrete flooring. Storage and use of liquid oxygen in base reservoir containers and portable containers comply with sections NFPA 99-2012: 11.7.2–11.7.4. (For full text, refer to NFPA 99-2012: 11.5.2.2; 11.5.2.3.1; 11.5.2.3.2; 11.7.2–11.7.4)

EP14 - The hospital meets all other NFPA 99-2012: Health Care Facilities Code requirements related to gas and vacuum systems and gas equipment. (For full text, refer to NFPA 99-2012: Chapters 5 and 11)Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital meets the applicable provisions of the Health Care Facilities Code Tentative Interim Amendments (TIAs) 12-4 and 12-6.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.