Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
Compliance tips for:
13.05.11 Medical gas systems and equipment: Maintenance
The standard focuses on storage requirements for gas cylinders. Medical piping systems must be labeled with the gas contained. Systems and alarm panels must undergo documented inspection and testing with a risk assessment for any period longer than one year. ■ Audit cylinder storage to ensure flammable liquids, gases and vapors are not stored with oxidizing gases. ■ Audit that upright cylinder storage includes a method to secure the materials. ■ Review hospital policies to ensure monitoring and maintenance comply with NFPA requirements
Nerd Newbies (understand the requirement)
Note: For surveys that took place between June 1, 2024, and April 6, 2025, this standard was numbered 13.05.10.
Frequency of the citation: 29%
Nerd Apprentices (audit for excellence)
Overview of the requirement: Storage of medical gas cylinders must meet requirements based on the volume of cylinders and size of the storage space. Oxygen, compressed air, vacuum systems, and equipment must be routinely monitored and maintained. Comment on deficiencies: Compliance is assessed through observation and document review. Surveyors noted issues with: ■ Labeling and identification. ■ Zone valve location. ■ Cylinder storage quantity. ■ Cylinder security and signage. ■ Compliance with storage requirements. Examples of ACHC Surveyor findings: ■ The medical gas alarm panel at the second-floor nurse's station 2 was not labeled to identify the area served by the panel. ■ The medical gas zone valves located in the pre-surgery/PACU area are not separated from the gas outlets they control by an intervening wall. ■ The medical gas storage room for the critical care unit contained in excess of 300 cubic feet (14 "E" O 2 cylinders), exceeding the allowable storage of medical gas cylinders in the smoke compartment. ■ On the first floor at the MRI equipment room, a helium cylinder "H" tank was in storage, unsecured, and without the signage required by code: POSITIVE PRESSURE GASES, NO SMOKING OR OPEN FLAME, ROOM MAY HAVE INSUFFICIENT OXYGEN. OPEN DOOR AND ALLOW ROOM TO VENTILATE BEFORE ENTERING. on the door. ■ Oxygen cylinders were observed stored less than five feet from combustibles.
Nerd Trailblazers (prepare the path for others)
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