Testing 100% of outlets annually?

  • Wednesday, July 21, 2021 7:00 PM
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    Message # 10766701
    Corky Bishop

    I keep hearing that The Joint Commission demands that hospitals must have 100% of medical gas outlets tested annually or else they will write them up.  Where does it say this in writing?


    I don't believe that we should be unplugging patients from their prescribed treatments if we are not licensed medical professionals.  


    It is also not good practice to wander in and out of contact precaution rooms along with all the rest of the occupied patient rooms.  


    Have any of you been asked to talk to TJC inspectors-in-training about medical gas requirements?  
  • Thursday, July 22, 2021 7:30 AM
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    Reply # 10767634 on 10766701
    Cary Darden (Administrator)

    Corky,


    I have heard a slightly different variation of this 100% testing requirement, which is that facilities are supposed to test 100% of "critical-care" outlets (or really category 1 spaces) annually.  This still is not written down anywhere in NFPA 99 and TJC actually posted an FAQ on their site on 3/19/2021 which basically states that they "are not prescriptive regarding testing frequencies for piped medical gas and vacuum systems."


    https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/environment-of-care-ec/000001266/
  • Thursday, July 22, 2021 5:35 PM
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    Reply # 10768788 on 10766701
    Larry Schutt

    ASSE 6000 does refer to this


    D.3.5 

    Check all outlets in critical care areas: Flow, pressure/vacuum, damage and wear (e.g., ICU, CCU, NICU, Surgery, Recovery, ER).
  • Thursday, July 22, 2021 6:32 PM
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    Reply # 10768864 on 10766701
    Al Moon (Administrator)

    The plain and simple fact is.


    IT IS NOT A REQUIRED OR A SHALL BE ITEM WITHIN NFPA 99 OR ASSE SERIES 6000 OR IN THE JOINT COMMISSION COMMISSIONING:




    ASSE SECTION #D.3.5 is listed in the ANNEX:

    This annex is provided for informational purposes only and is
    not a mandatory part of ASSE Standard 6010. 
  • Friday, July 23, 2021 10:33 AM
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    Reply # 10770063 on 10766701
    Cary Darden (Administrator)

    Larry,


    That is a good point, I didn't think about the fact that ASSE had that verbiage in annex D.  As Al has already pointed out however, that is located within the non-mandatory portion of the book.
  • Thursday, July 29, 2021 11:03 AM
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    Reply # 10782357 on 10766701
    Robert Kroening

    I have not heard this demand from a Joint Commissions surveyor.

    I suspect that it may be that the facility either has a statement in their policy that makes similar statement, or they do not have a written policy, and the surveyor is defaulting to the statement in the ASSE 6000 document.

    As stated by the other responses, there is not a requirement for frequency of testing, only that they need to write a policy that identifies how often they will be tested.

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