PCREE Compliance Audit Worksheet

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Compliance Score

Complete the checklist below to see your score.

Based on items answered Yes out of total answered

1. Equipment Inventory

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We maintain a complete written inventory of all patient care related electrical equipment (PCREE) in the facility. High

NFPA 99 §10.2 — Equipment Management Plan requirement

The inventory includes manufacturer, model, serial number, and asset number for each device. High

Required for device-level documentation that CMS surveyors review

The inventory is updated when new equipment is acquired and when equipment is retired. Medium

Ongoing inventory maintenance — prevents gaps in testing coverage

Electrical receptacles in all patient care rooms are included in our PCREE inventory and testing program. High

NFPA 99 §6.3.3.2 — commonly missed requirement

2. Testing Currency

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All PCREE devices have been tested within the past 12 months. High

NFPA 99 §10.2 — annual minimum requirement

All new equipment received in the past 12 months was tested before first patient use. High

NFPA 99 — pre-use testing required regardless of whether equipment is new

Any device repaired or modified in the past 12 months was retested before being returned to patient care. High

NFPA 99 — post-repair testing required for all repairs, not just electrical repairs

Patient care room electrical receptacles were tested for polarity, ground continuity, and retention force within the past 12 months. High

NFPA 99 §6.3.3.2 — receptacle testing is a separate requirement from equipment testing

3. Documentation Quality

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Test records include actual measured values (in µA and Ω) for each parameter — not just "pass" notations. High

CMS surveyors expect to see quantitative values — "pass" without measurements is insufficient

Each test record includes the technician's full name and qualification documentation. High

NFPA 99 "qualified personnel" requirement — surveyor will look for this

Test records are organized by device and readily retrievable within 15 minutes during a survey. Medium

Surveyors may request records with little warning — retrieval delay is a red flag

Devices that failed testing have documented corrective actions, removal-from-service dates, repair records, and post-repair retest results. High

Incomplete corrective action documentation is a common secondary citation

We maintain at least 2–3 years of historical PCREE testing records. Medium

Surveyors may request historical records when evaluating compliance patterns

4. Program Management & Technician Qualifications

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We have a written Equipment Management Plan (EMP) that describes our PCREE testing program. High

NFPA 99 §10.2.2 — the EMP is required, not optional

The technician who performs our PCREE testing has documented training and experience. High

NFPA 99 "qualified personnel" requirement — documented qualifications are the defensible standard

We have verified that our biomedical technician's ESA (electrical safety analyzer) has a current NIST-traceable calibration certificate. Medium

Uncalibrated equipment produces measurements that may be legally challenged

Annual testing is scheduled at least 4–6 weeks before our anticipated survey window. Medium

Allows time for corrective action on failed devices before survey

Staff know not to use equipment removed from service for leakage current failures until it has been retested and cleared. Medium

Equipment returned to service without post-repair testing is a citation risk

Compliance Gaps Identified

Complete the checklist above to see your gaps listed here.

Compliance Gaps Identified

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