May 22 2017

Retainage of Documentation

Category: Documentation,Questions and AnswersBKeyes @ 12:00 am
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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.


Feb 09 2017

Life Safety Inspections at Offsite Locations

Category: Documentation,Questions and Answers,TestingBKeyes @ 12:00 am
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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.