Maintaining Testing/Inspection Documents

Q: Our organization is accredited by Joint Commission. I know for inspection purposes we need to have the current year plus that past three years of documentation for LS and EC standards such as fire extinguisher, emergency lights, emergency generator, med gas testing etc. We currently have years and years of documentation being stored. Can these be disposed of or do we need to keep it because we need to keep records of all devices? I hope I’m explaining myself well.

A: I fully understand what you’re saying and you explained yourself well. Your questions is, can you dispose of testing/inspection documents older than 3 years? Well…. I guess you could, but I certainly would not recommend it.

A couple of years ago, during a Joint Commission survey, a surveyor asked a client of mine to produce a document to ensure a particular item was replaced and retested from seven (7) years prior. Fortunately, the client was able to produce that document, but it surprised the client (and me) that a surveyor would want to look at a document that was seven years old.

I understand that Joint Commission surveyors can and often do ask for documentation that goes back 3 years, so obviously having 3-years’ worth of documentation available is a necessity. But there are other reasons to maintain testing/inspection document, such as evidence for litigation cases. While one hopes they never have to utilize documents for that reason, it is a real possibility.

When I was Safety officer at the hospital where I worked, I found strategic storage areas where I kept my old testing/inspection documents. But if you’re asking if there are NFPA codes or standards, or Joint Commission standards that require maintaining these documents for any particular length of time, I would say no… I’m not aware of that.

Retainage of Documentation

Q: How long does Joint Commission require records to be kept on inspections like fire alarm systems, fire drills, sprinklers, fire dampers, and PM records for beds and refrigerators, etc.? We have files going back 30+ years on paper, and a whole room of file cabinets to house it all.

A: My advice is to never throw away any document that confirms a regulatory requirement, such as test and inspection reports. The Joint Commission often times will request documentation as far back as the last triennial survey or the last test/inspection frequency, whichever is longest. However, I had a client recently that was challenged by a Joint Commission surveyor to prove that a repair was made from a 7-year old deficiency report. Fortunately they had the document, but without it they might have been cited by the surveyor.

Other authorities, such as your state agency who surveys on behalf of CMS, may require that you retain the documents longer.

Life Safety Inspections at Offsite Locations

Q: For off-site satellite facilities, where the building is not owned by the hospital but where the space inside the building is licensed by the hospital, are monthly fire extinguisher inspections required? We have several off-site laboratories and other services in buildings that we do not own.

A: Yes… you must maintain all of the features of Life Safety at the offsite locations, even those that you do not own; the same as you would at the main hospital. Just because you do not own the fire extinguishers, fire alarm system, sprinkler system, fire dampers, exit signs, generator, elevators, medical gas systems, and fire doors does not give you a pass on not properly maintaining them. I understand that landlords rarely conduct the same level of testing and inspection of their building’s fire safety features as you would at the hospital, but the rules for testing and inspection apply evenly across all facilities where you have staff and patients, regardless who owns it. Your survey team may not always ask to see the documentation for testing and inspecting these systems at the offsite locations, but it is a requirement found in the core chapters and occupancy chapters of the Life Safety Code.

Retaining Documentation

Q: Is there a retention requirement for eyewash weekly testing logs? One source I’ve read indicates at least 2 years.

A: You need to retain all evidence that documents you have complied with regulatory standards as long as your authorities having jurisdiction tells you to do so. Having said that, not all AHJs actually say how long to retain documents. I know Joint Commission expects to see three years’ worth of documents to prove compliance with their standards. Other accreditors are not as clear. My advice is to never throw away any documents… keep them for the life of the building. You should be able to purge your files and box up the documents and place them in storage somewhere.

Fire Extinguisher Documentation

fire-extinguisher-sm[1]A surveyor recently cited an organization stating the hospital did not have a document indicating all of the portable fire extinguishers were inspected on a monthly basis. The surveyor asked for a document whereby the organization knows where each portable fire extinguisher is located, and assurance that each extinguisher received its monthly inspection. The hospital did not have such a document and the surveyor cited them for non-compliance with the standard that addresses portable fire extinguishers.

A subsequent conversation with the facility manager of the organization revealed that every portable fire extinguisher that the surveyor inspected did in fact have an annual maintenance tag with the monthly inspections properly identified on each extinguisher. Apparently, the surveyor thought the hospital should have a master list indicating the locations of each portable fire extinguisher, along with documentation that they were inspected monthly. This master list indicating the locations of all the fire extinguishers is a fine idea, but it is not a requirement for compliance with any NFPA code or standard, nor any accreditation organization’s standard. This is what is called “Best Practice” and is not required to be enforced upon the healthcare organizations. Best Practice may be shared with the organization by the surveyor as a suggestion on how they may make improvements, but it is not a requirement. Be assured that NFPA codes and standards do require documentation of the monthly inspections of the fire extinguishers, but they do not stipulate how that inspection is to be documented. Some hospitals like to use the bar-code method to document the inspection, but the most common approach to document this monthly inspection is to mark the date (month and day) along with the initials of the inspector on the annual maintenance tag attached to the extinguisher.

This finding was removed from the survey report during the clarification process.

Comments on Electronic Documentation From a State Inspector

I never know who is reading (or not reading) my blog, but recently I received the following comment from a state department of public health individual who inspects hospitals. He had this to say concerning my recent article on electronic documentation:

On your article for electronic documentation, our finding is the documentation will have to have  all the pertaining information required. I do not accept any electronic documentation on a survey, such as TELS, in replacement of the documentation provided by the inspection company for sprinklers, fire alarm, or any other entity required to perform quarterly, semi annual, or annual inspections. For internal items by qualified personnel such as generator testing, emergency lighting testing, emergency evacuation/fire drills or monthly smoke detection inspection/testing, I do accept electronic versions if they contain all the elements such as those you noted in your article. It has been brought to my  attention on many surveys that some of the larger facilities who work between different states are suggesting to their maintenance personnel that they do strictly electronic entries and not keep hard copy records. My response is always the same: “It depends”. Whomever is the AHJ for the locale, region, or state will be the one to make that determination.

I appreciate his insight and comments. If you similarly have comments on any of my articles or Q&As, please feel free to send me a note.

Follow-Up on Documentation

imagesIDI1GACXMy recent series of articles on Documentation created quite a bit of response. One individual had this question:

“What is your opinion of documentation being kept electronically rather than in hard copy format?  We will have things organized and easy to find and search, but I don’t want to go through the process of electronic files if a surveyor is going to request hard copies.”

My understanding is most authorities will accept electronic documentation provided it meets all of the requirements for documentation. Many AHJs have specific requirements concerning what’s included in the documentation, such as:

Testing & Inspection- Documentation.

Unless otherwise stated, testing, inspection and maintenance documentation must include, at the minimum, the following information:

  1. Name of individual performing the activity
  2. Affiliation of the individual performing the activity
  3. The signature of the individual performing the activity
  4. Activity name
  5. Date(s) (month/day/year) that activity was performed
  6. The frequency that is required of the activity
  7. The NFPA code or standard which requires the activity to be performed
  8. The results of the activity, such as ‘Pass’ or ‘Fail’

An electronic signature typically would be acceptable in lieu of a hand-written signature. That usually means the technician performing the work would have to enter the data in order to create the electronic signature. Most authorities would not accept an electronic signature from a data-entry person in lieu of the technician performing the work. Most authorities also would not accept a data-entry person issuing an electronic signature of another individual, such as a jpg picture of a signature. However, pdf copies of documentation with all of the above requirements is acceptable. Essentially, it would be similar to a photo-copy of a report.

There are stories of the data-entry person not being present during the survey and they were the only one with the passcodes to access the data, or with the knowledge on how to retrieve the data. I also witnessed a situation where weekly reports were turned into a clerical person to enter the data into the computer. The clerical person allowed the reports to accumulate and the data was not entered during the week that the test/inspection was performed. The data-entry person used the ‘default’ date stamp provided by the software platform when the data was entered, which effectively said the test/inspection was not performed during the required time-period.

It is difficult to attach follow-up reports to electronic copies, such as ILSM assessments or repair work orders to a particular LSC deficiency. With paper files, they can easily be inserted into a binder or a folder.

Bottom line: Electronic documentation is permitted, but most hospitals realize the risks do not out-weigh the rewards. I am not a fan of electronic documentation because I have witnessed the problems with using them. But as with all technology, time is needed to work out the problems and make improvements. I’m an old man, and perhaps the younger generation has already implemented solutions to this problem.

I welcome your feedback on the use of electronic documentation.

Fire Alarm Test Reports

fire-alarm-system-detects-protects-24-x-7-250x250[1]Fire alarm test reports are the number one item that surveyors look at during the document review session. It is also the number one document that draws the most findings and citations, mainly because there are so many devices connected to the fire alarm system. A typical 200 bed hospital may have over 2,000 devices connected to the fire alarm system that need to be tested.

Nearly all of the requirements for the frequency of the tests performed on fire alarm systems can be found under NFPA 72 (1999 edition), section 7-3.2. The one exception would be the requirement for the water-flow switch testing which is found under NFPA 25 (1998 edition), section 2-3.3. (NOTE: This does not take into consideration the recent CMS categorical waivers.)

Often times a contractor performing the fire alarm testing will not test all of the devices listed below, even if your hospital has them in your system. The reasons may differ but the bottom line is the hospital facility manager must review the contract and determine what is actually required. Many times the standard contract (or signed proposal) will state something to the effect the fire alarm system will be tested in accordance with NFPA 72, although it doesn’t always refer to the proper edition (most hospitals are on the 1999 edition of NFPA 72). If the contract says it will test to NFPA 72, then you must hold them accountable for testing everything on the list below.

Make sure the test report lists the complete inventory of each and every device connected to the fire alarm system. All of the initiating devices, all of the occupant notification devices and all of the interface relays must be listed in an inventory complete with their location and whether they passed or failed their test. And don’t forget all of the batteries in the fire alarm system, not just those in the fire alarm control panel. There may be other batteries involved such as those in a remote panel or a Notification Appliance Circuit (NAC) extender panel.

Here is a list of devices that could be connected to the typical fire alarm system in a hospital:



Initiating   Devices

Water-flow switches


Smoke detectors


Heat detectors


Duct detectors


Manual pull stations


Supervisory   Signal Devices

Low air pressure switches


Low water level switches


Tamper switches


Notification   Devices









Interface   relays and modules

Magnetic hold-open


Air handler shut-down


Kitchen hood suppression sys


Elevator recall


Magnetic locks


Fire pump


Smoke dampers


CO2/Clean agent suppression


Sprinkler dry-pipe/pre-action


Overhead rolling fire doors


Control   panel batteries

Charger test


Discharge test


Load voltage test


Smoke   detector sensitivity test


Off-premises   monitoring transmission equipment


Here are some basic requirements about the fire alarm test report:

  • Make sure the report is dated and signed by the service technician and you (the owner’s representative)
  • Make sure all the devices connected to the fire alarm system are accounted for and inventoried in the report
  • Make sure resettable heat detectors are ‘tested’ rather than ‘inspected’. Lazy technicians may not want to get out the hot-air guns to test the heat detectors so they just ‘inspect’ them
  • Make sure the heat detectors are tested with heat, and not with magnets. Only the one-shot non-resettable heat detectors are permitted to be tested with magnets.
  • When items on the report are identified as having ‘failed’ their test, make sure there is follow-up action to resolve the issue
  • Don’t forget to assesse the failed devices for Interim Life Safety Measures (ILSM)
  • Resolve all deficiencies and staple copies of the paperwork that demonstrates the repair was completed, along with a re-test, to the test report
  • Ensure that the technician performing the fire alarm testing, service and repairs meets the qualifications for certification or licensing. This applies to in-house staff or contracted staff. Have the qualifying documents on file.

Maintain your fire alarm test report at this level of documentation and you should not have any troubles with the surveyors.


Documentation – Part 4: The Rest of the Story


This is the last in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during a survey.

When you’re finished with this update and improvement to your documentation for life safety equipment, you should have a very nice row of binders, not unlike the picture to the left. Many hospitals maintain these binders on a cart so they can be wheeled anywhere they are needed in a moment’s notice.

When I was the Safety Officer at the hospital where I worked, I kept these documents in my office where I could keep an eye on them. When the time came for the document review session, I just wheeled the cart into the respective conference room and let the show begin.

One last comment I want to bring to your attention… I was at the Joint Commission home office in Oakbrook Terrace, IL, earlier this spring and George Mills (director of engineering for Joint Commission) was speaking to a group of hospital engineers from Northern Illinois, and he mentioned that Joint Commission is taking a much tougher stand on the documentation of the life safety features in the hospital. He explained that there will be new consequences to multiple findings under standard EC.02.03.05, and made this announcement:

“If we write findings in three (3) or more EPs in EC.02.03.05, we are also writing a finding under the leadership standard, LD.04.01.05, EP 4 which says leadership must hold staff accountable for their responsibilities” said Mills. “If this is the way that the fire safety features are managed, shouldn’t there be some repercussions? Then the facility manager can explain to the CEO why it is okay to not know the level of reliability of the fire alarm system. It’s all about managing the process.”

So… You have it straight from George’s mouth: The Joint Commission in cracking down on multiple (3 or more) findings under the standard that governs testing and inspection of the life safety features in the hospital. And remember: If you performed the test or inspection but do not have the documentation to prove it… it is still a finding and the AHJ will cite you for non-compliance.

As a reminder… If you want to download the entire document review sheet that this article is based on, go to “Tools” page, and look under “Life Safety Document Review Session” heading, and click on “Acute Care Hospital Documentation Requirements”.

Now, as promised, the rest of the documents that need to be included for the document review session:



NFPA   Standard

Portable   fire extinguishers



10-1998; 4-3.1



10-1998; 4-4.1

Alternative   suppression systems

Kitchen hood system – inspection


17A-1998; 5-2.1

Kitchen hood system – test


17A-1998; 5-3.1.1

Halon system – inspection & test


12A-1997; 4-1.1

CO2 system – inspection


12-1998; 1-10.1

CO2 system – tank weigh


12-1998; 1-10.3.5

CO2 system – test


12-1998; 1-10.3.2

Clean agent system – inspection


2001-2000; 4-1.3

Clean agent system – test


2001-2000; 4-1.1

Emergency   power generators



110-1999; 6-4.1

Battery electrolyte levels


110-1999; 6-3.6

Monthly load test

No less than 20 days; no more than 40   days

110-1999; 6-4.2 and 99-1999; 3-

Annual load test (if required)


110-1999; 6-4.2.2

3-Year 4-Hour load test


110-2005; 8.4.9

Automatic   Transfer Switches

Monthly test with generator

No less than 20 days; no more than 40   days

110-1999; 6-4.5 and 99-1999; 3-

Medical   gas and Vacuum sys

Maintenance & testing

As per policy, but not more than 12   months without risk assessment

99-1999; 4-

Cross-contamination test

After breaching of system

99-1999; 4-

Purity and pressure test

After breaching of system

99-1999; 4-

Alternative   Life Safety Measures


Review policy



Review implementation documents


Fire Watch

Review fire watch documents

101-2000; &   101-2000;

Fire/Smoke   damper test

Inside hospital facility

1-Year after installation; Every 6   years thereafter

80-2007; 19.4 and 105-2007; 6.5.2

Outside hospital facility

1-Year after installation; Every 4 years   thereafter

80-2007; 19.4 and 105-2007; 6.5.2

Horizontal   sliding/Vertical rolling fire doors

Drop test


80-1999; 15-2.4.3

‘Exit’   signs

Illumination inspection



Elevator   recall

Test of all elevators equipped with   Fire Fighter Service


101-2000; 9.4.6

Fire   Drills

Healthcare occupancy

Quarterly on each shift


Documentation- Part 3: Sprinkler System

imagesJ0Z09XQXThis is the third in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during a survey.

Last week I talked about the fire alarm system testing documentation. There are potentially over 25 different devices that a typical hospital fire alarm system may have, and some hospitals tend to over-look the occupant notification devices and the interface relays. Make sure your reports include these devices.

Sprinkler systems have many different components, most of which are hidden from view to the general public. If you haven’t already, take the time to investigate whether or not you have these devices in your facility. It is unlikely that any hospital would have every device listed below, but all of these devices have been observed in one healthcare institution or another.



NFPA   Standard

Fire pump churn test


25-1998; 5-3.2.1

Control valve inspection


25-1998; 9-3.3.1

Fire department connections


25-1998; 9-7.1

Pre-action/Dry pipe valve priming   water test


25-1998; 9-

Sprinkler inspection


25-1998; 2-2.1.1

Piping & hanger inspection


25-1998; 2-2.2

Pre-action/Dry pipe valve trip test


25-1998; 9-

Main drain test


25-1998; 9-2.6

Control valve exercise


25-1998; 9-3.4.1

Backflow preventer


25-1998; 9-6.2

Anti-freeze test


25-1998; 2-3.4

Private service fire hydrants


25-1998; 4-3.2

Fire pump flow test


25-1998; 5-3.3.1

Occupant use fire hose – inspection


1962-1998; 2-3.3

Occupant use fire hose – pressure   test

5-Years after installation; then   every 3-Years

1962-1998; 2-3.2

Check valve inspection


25-1998; 9-4.2.1

Pressure gauge calibration


25-1998; 2-3.2

Standpipe waterflow test


25-1998; 3-3.1

Private fire service mains


25-1998; 4-3.1

Internal inspection of system piping   (if obstruction conditions)


25-1998; 10-2.2

QR sprinkler head replacement


25-1998; 2-3.1.1

SR sprinkler head replacement


25-1998; 2-3.1.1

If you contract your sprinkler system testing and inspection activities, take this list and sit down with your contractor and review with them if they are performing these functions. The above list does not take into consideration any alternative frequencies based on the CMS categorical waivers.

If you want to download a copy of the complete list of requirements for the document review session, go to “Tools” page, and click on “Acute Care Hospital Documentation Requirements”. You will find the file under the Life Safety Document Review heading.

Next week we will look at the final installment and rest of the list of items needed for the document review session.