Hospitals and Care Facilities must document this testing to maintain accreditation.

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đź“Ś What the Joint Commission Actually Enforces
The Joint Commission’s Environment of Care (EC) and Physical Environment (PE) chapters reference NFPA 110 for emergency power systems.
NFPA 110 requires:

  1. Annual Fuel Quality Test (Mandatory)
  • NFPA 110 §8.3.7:
    “A fuel quality test shall be performed at least annually using appropriate ASTM standards.”
  • ASTM D975 and related tests are typically used.
  1. Documentation Requirements
    Hospitals must maintain:

Generator test logs (monthly, annual, triennial)
Joint Commission surveyors frequently cite missing or undocumented fuel testing as a deficiency.

Annual fuel test results

Corrective actions if fuel fails

Sampling records

Why This Matters for Joint Commission Surveys
Healthcare facilities face overlapping requirements from:

  • CMS (federal law)
  • Joint Commission (accreditation)
  • NFPA 110 (technical standard)
    Fuel quality is one of the most common failure points because hospitals often test generators but not the fuel feeding them.

Action Checklist for Compliance
To be fully compliant for Joint Commission surveys:

  1. Perform Annual Fuel Testing
  • Use ASTM‑based lab tests
  • Document results
  • Retain records for survey review
  1. Sample Correctly
  • Pull samples from the bottom of the tank, not the day tank
  • Use proper sampling containers
  • Document chain of custody
  1. Take Corrective Action if Fuel Fails
  • Polish the fuel
  • Remove water
  • Treat microbial contamination
  • Retest and document
  1. Keep Records Organized
    Surveyors will ask for:
  • Annual fuel test report
  • Generator monthly load test logs
  • Triennial 4‑hour load test documentation (NFPA 110 §8.4.9.7)

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