Medical Equipment Survey Checklist for Texas Healthcare Facilities

A survey rarely fails on one broken device. It fails on records: a monitor with no inspection sticker, an infusion pump missing from the inventory, a preventive maintenance (PM) date that slipped three months with no note explaining why. Surveyors check equipment by checking paperwork first.

This checklist is for hospitals, surgery centers and clinics in Texas preparing for a CMS, Joint Commission or state survey. Work through it a month before the survey window opens, and keep it running after the surveyors leave.

What surveyors look at

The rules come from three places, and they overlap more than they differ.

• CMS. The hospital Conditions of Participation say that "facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality" (42 CFR 482.41). CMS guidance lets a hospital move some equipment from the manufacturer's schedule to its own risk-based program, called an Alternate Equipment Management (AEM) program. Imaging and radiologic equipment, medical lasers, and new equipment without enough maintenance history must stay on the manufacturer's schedule.
• The Joint Commission. From January 1, 2026, hospital standards for the building and equipment sit in a new Physical Environment chapter, which replaced the Environment of Care chapter. The three old requirements on inspecting, testing and maintaining medical equipment became one: the hospital maintains essential equipment in safe operating condition. If your policies still quote the old EC numbers, update them.
• Texas DSHS. Facilities with X-ray equipment must keep their radiation machine registration current and follow the state rules for who may install, repair and evaluate that equipment (more in section 5).

In every case the surveyor asks the same three questions: do you know what equipment you have, do you maintain it on the schedule you set, and can you prove it?

1. Equipment inventory and risk levels

Everything else depends on the inventory. A device that is not on the list has no PM schedule, no inspection history and no owner, and surveyors find these devices by walking the floor and reading asset tags.

• Every piece of medical equipment in use has an asset tag and appears in the inventory, including rentals, loaners and devices that physicians brought in.
• Each entry shows make, model, serial number, location, department and the date it entered service.
• Each device has a risk level, with life-support and high-risk equipment (ventilators, defibrillators, anesthesia machines, infusion pumps) clearly marked.
• Each device shows its maintenance strategy: the manufacturer's schedule or your AEM program, with the reason written down for anything on AEM.
• Imaging equipment, medical lasers and new equipment are on the manufacturer's schedule, not AEM.
• Retired or removed devices are marked as such, with the date and where they went.
• A floor walk of two or three departments matches the inventory, tag for tag.

If the inventory has never been checked against the floor, start there. An annual medical equipment inspection tags, tests and documents each device, so the list and the floor agree before the surveyor compares them.

2. Preventive maintenance: schedules and completion

Surveyors pick a few devices from the inventory and ask for their PM history. What they want to see is simple: the schedule you set, and proof you kept it.

• Every device has a PM interval, taken from the manufacturer's instructions or from your AEM program.
• PM for high-risk and life-support equipment is complete. Anything overdue has a written reason and a new date, not just a blank.
• PM work orders show the date, the technician, the tests performed, the results and the test equipment used.
• The test equipment itself (safety analyzers, simulators, meters) has current calibration certificates.
• Devices that failed PM were tagged out of service, repaired and retested before going back to patients, and the record shows each step.
• Devices that could not be found at PM time are marked as missing and followed up, not skipped silently.
• If you use an AEM program, the policy is written, approved and followed exactly. CMS expects hospitals to stick strictly to the frequencies they choose.

When PM backlog is the problem, a scheduled medical equipment maintenance program clears it faster than catching up device by device, and leaves records in the format surveyors expect.

3. Electrical safety, calibration and incoming inspection

CMS surveys electrical equipment against NFPA 99 (2012 edition), which calls for physical integrity, resistance, leakage current and touch current tests on patient-care-related electrical equipment. The standard leaves the testing interval to your own policy, but it expects that equipment to be tested before it is first put into service.

• Your policy states how often each type of patient-care equipment gets electrical safety testing, and the records match the policy.
• Each test record shows ground resistance, leakage current and the pass or fail result, not just "OK".
• Power cords, plugs and strain reliefs are checked at every PM; damaged cords are replaced, not taped.
• Devices that measure or deliver something (patient monitors, defibrillators, infusion pumps, scales, thermometers) are calibrated to the manufacturer's specifications, with the readings recorded.
• Every new, rented or loaned device gets an incoming inspection and electrical safety test before its first patient use, and goes into the inventory the same day.
• Equipment brought in by staff or vendors (fans, heaters, phone chargers near patients) follows your policy for non-medical electrical equipment.

Rentals catch facilities out more often than new purchases, because they arrive in a hurry. Ask your rental company for the inspection and safety test record with each delivery, and keep it with your own incoming check.

4. Work orders, recalls and incident reports

PM records show the plan. Work orders, recall files and incident reports show what happened when something went wrong, and surveyors read them to see whether problems were closed or just logged.

• Every repair has a work order with the problem reported, what was found, the parts used, the test after repair and the date the device went back into service.
• Repeat failures on the same device are visible in its history, with a decision recorded: repair again, replace or retire.
• Recalls and safety notices from the FDA and manufacturers are checked against the inventory, and each affected serial number shows the action taken and the date.
• Device-related incidents are investigated, and the device is pulled and kept as found when it may have caused harm.
• Hospitals, surgery centers, nursing homes and outpatient treatment facilities know their FDA reporting duty: a death that a device may have caused or contributed to goes to the FDA and the manufacturer, and a serious injury goes to the manufacturer, each within 10 work days of becoming aware of it.
• Staff who operate high-risk equipment have training records, and new devices come with in-service training before use.
• Records are easy to pull. If it takes an hour to find one device's history, the surveyor will notice.

One binder or one software system for all of this is better than three partial ones. Whatever you use, the asset tag number should link the inventory, the PM records, the work orders and the recall log.

5. X-ray and imaging equipment in Texas

Imaging gets extra attention because two sets of rules apply. CMS guidance keeps all imaging and radiologic equipment on the manufacturer's maintenance schedule, and Texas DSHS adds its own registration and evaluation rules under Title 25, Chapter 289 of the Texas Administrative Code.

• Your DSHS certificate of registration for radiation machines is current and on file.
• Every company that installs or repairs your X-ray equipment has given you proof of its DSHS registration. Texas rules say a registrant may not use a service provider until it has that evidence, so keep a copy with your records.
• An equipment performance evaluation (EPE) was done within 30 days of each installation or re-installation.
• After any repair to a part that affects radiation output, such as the tube, timer or power supply, a licensed medical physicist decided whether a new EPE was needed, and the decision is on file.
• Routine EPEs are up to date on the schedule DSHS sets for your type of equipment.
• PM for X-ray, C-arm machines, CT and ultrasound follows the manufacturer's schedule, with the service reports filed by serial number.

Check the DSHS rules for your own facility type, because requirements differ between hospitals, clinics, dental and veterinary practices.

A 30-day plan before your survey

1. Week 1: fix the inventory. Walk every department, match asset tags to the list, add what is missing, and mark retired devices.
2. Week 2: close high-risk PM. Finish every overdue PM on life-support and high-risk equipment first, then the rest. Write a reason and a new date for anything you cannot finish.
3. Week 3: safety and recalls. Run electrical safety tests that are due, check recall notices against your serial numbers, and confirm test equipment calibration.
4. Week 4: run a mock survey. Pick ten devices at random and pull each one's inventory entry, last PM, last safety test and open work orders. If any record takes more than a few minutes to find, fix the filing before the real survey.

How Mr. Biomed Tech Services can help

Our CBET-certified engineers inspect, maintain and repair medical equipment to manufacturer specifications and AAMI guidelines, and leave records organized by asset tag so they are ready when surveyors ask. That work supports your Joint Commission, CMS and DSHS requirements; it does not replace your own policies.

• Before a survey: an annual medical equipment inspection to tag, test and document your equipment, or a catch-up visit to clear overdue PM.
• All year: clinical engineering services for facilities that need an outsourced biomed team to run the inventory, PM schedule and recall checks.
• When equipment is retired: documented medical equipment disposition, so removed devices leave your inventory with a record.

We serve Texas facilities within about 300 miles of our Garland headquarters, Monday to Friday, with responses in under 8 business hours and same-day on-site service across Dallas–Fort Worth. Call (469) 767-8853 or send us a request to plan your pre-survey visit.