Medical Gas System Inspection Documentation Lacking
Penalty
Summary
The facility failed to maintain compliance with medical gas system requirements, as evidenced by the absence of documentation verifying that an annual inspection of the medical gas system was performed. This deficiency was identified during a document review and interview conducted on February 4, 2025, at 8:45 a.m. The Facility Administrator confirmed that the necessary documentation for the medical gas system inspection was not available at the time of the survey. This oversight affected the entire facility, as the required elements of the gas and vacuum systems inspection and testing were not documented as part of the maintenance program.
Plan Of Correction
908 main 1 1. A new vendor was contacted to complete the annual medical gas system inspection. 2. An ongoing audit is conducted and reviewed by the Director of maintenance or Designee to ensure continued annual medical gas system inspections are completed. 908 main 2 1. A new vendor was contacted to complete the annual medical gas system inspection. 2. An ongoing audit is conducted and reviewed by the Director of maintenance or Designee to ensure continued annual medical gas system inspections are completed.