Pittsburgh, PA. — Every HTM department has had this conversation. A device is due for its inspection, testing, and maintenance, and nobody can put a hand on it. It’s not in the room the asset record says it should be in. It’s not in the shop. Nobody notices until the completion report runs and there it is, sitting red.
I’ve given a talk called “I Swear I Looked!” more times than I can count at this point, and the title always gets a laugh, because everyone in the room has said exactly that sentence to a director, a surveyor, or themselves. Here’s the thing though: being unable to locate a piece of equipment isn’t automatically a compliance finding. What turns it into one is not having a documented answer to the next question, which is always “show me how you looked.”
That question just got sharper. Effective January 1, 2026, Joint Commission’s new standard, PE 04.01.01, replaced about 54 existing Elements of Performance, including the three that specifically governed how hospitals manage medical equipment inventories and unable to locate situations (the old EC 02.04.01 EP 2, EC 02.04.03 EP 2, and EC 02.04.03 EP 3). If your UTL policy was written around that old language, it’s worth pulling it back out.
Joint Commission accredits most U.S. hospitals, roughly 83% by the numbers I track, but it’s not the only game in town. DNV holds around 11%, and CIHQ another 3%. Each has its own version of the same underlying expectation, expressed in slightly different language: DNV’s PE.7 and CIHQ’s CE-8 both speak to safe, maintained equipment, and state surveyors layer on top of whichever of those you’re accredited under. First question before you rewrite anything: which authority are you actually being surveyed against, because that answer changes your citation, not your workload.
Whichever one applies, the completion bar doesn’t move. High-risk and non-high-risk equipment on an Alternative Equipment Maintenance schedule both carry a 100% completion expectation. A surveyor isn’t going to ask if you completed it. They’re going to ask if you can show it.
A few questions your policy needs to answer before someone else asks them for you. What counts as “in service,” and what has to get reported the moment it isn’t? How many attempts to locate does a tech have to make, and how are those attempts written down instead of just remembered? Who gets a call when equipment tied to their department goes missing? At what point does a device get moved to inactive, and if it turns up in a closet eight months later, what happens to its history?
None of that requires exotic technology. A real-time location system helps, sure, but it’s not required and it’s not the point. The point is a repeatable workflow: look for it, log the attempts, generate a follow-up work order when it’s still missing, change the asset’s status so the gap is visible instead of buried in a spreadsheet, and retire it from active inventory after a defined number of tries. If it shows back up, retest it, document that too, and put it back in service without losing its maintenance history.
The month-to-month discipline is what actually gets you through survey week, not a policy binder nobody’s opened since it was written. Every UTL asset needs a documented attempt trail and a completion percentage you can pull by risk classification, and if you’re multi-site, by facility.
An unmanaged UTL problem isn’t just a survey risk, it’s hours. Every asset a tech can’t find is time spent searching, an interval slipping past its due date, and a completion number that either overstates what actually happened or triggers a scramble the week before survey. Departments that treat UTL as a defined, documented workflow instead of an exception tend to end up with fewer things actually missing, because writing it down changes how people look.
That’s the workflow FSI’s CMMS is built to carry end to end, asset status changes, follow-up work orders, retirement thresholds, and completion reporting by risk classification, all tied to the same asset record instead of a side spreadsheet somebody forgets to update. It’s part of why 1,300+ hospital departments run their equipment programs on FSI.
If PE 04.01.01, or whichever standard your facility answers to, has you rethinking how unable to locate gets documented, I’m happy to walk through what that looks like inside FSI's CMMS.
About FSI:
FSI is healthcare’s leading CMMS, purpose-built to support healthcare facilities management (HFM) and healthcare technology management (HTM) teams. Trusted by hospitals and health systems nationwide, FSI helps organizations improve compliance readiness, streamline maintenance operations, and protect patient safety through intuitive, configurable technology.