Mar 14 2016

Retaining Documentation

Category: BlogBKeyes @ 12:00 am
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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.

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Feb 05 2015

Fire Extinguisher Documentation

Category: BlogBKeyes @ 6:00 am
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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.

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Aug 21 2014

Comments on Electronic Documentation From a State Inspector

Category: BlogBKeyes @ 6:00 am
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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.

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Jul 17 2014

Follow-Up on Documentation

Category: BlogBKeyes @ 5:00 am
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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.

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May 15 2014

Fire Alarm Test Reports

Category: BlogBKeyes @ 5:00 am
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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:

Device/Test

Frequency

Initiating   Devices

Water-flow switches

Quarterly

Smoke detectors

Annually

Heat detectors

Annually

Duct detectors

Annually

Manual pull stations

Annually

Supervisory   Signal Devices

Low air pressure switches

Quarterly

Low water level switches

Quarterly

Tamper switches

Semi-annually

Notification   Devices

Strobes

Annually

Horns

Annually

Bells

Annually

Chimes

Annually

Interface   relays and modules

Magnetic hold-open

Annually

Air handler shut-down

Annually

Kitchen hood suppression sys

Annually

Elevator recall

Annually

Magnetic locks

Annually

Fire pump

Annually

Smoke dampers

Annually

CO2/Clean agent suppression

Annually

Sprinkler dry-pipe/pre-action

Annually

Overhead rolling fire doors

Annually

Control   panel batteries

Charger test

Annually

Discharge test

Annually

Load voltage test

Semi-annually

Smoke   detector sensitivity test

2-years

Off-premises   monitoring transmission equipment

Quarterly

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.

 

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May 01 2014

Documentation – Part 4: The Rest of the Story

Category: BlogBKeyes @ 5:00 am
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imagesAAC0F4DG

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:

Device/Test/Inspection

Frequency

NFPA   Standard

Portable   fire extinguishers

Inspection

Monthly

10-1998; 4-3.1

Maintenance

Annually

10-1998; 4-4.1

Alternative   suppression systems

Kitchen hood system – inspection

Monthly

17A-1998; 5-2.1

Kitchen hood system – test

Semi-annually

17A-1998; 5-3.1.1

Halon system – inspection & test

Semi-annually

12A-1997; 4-1.1

CO2 system – inspection

Monthly

12-1998; 1-10.1

CO2 system – tank weigh

Semi-annually

12-1998; 1-10.3.5

CO2 system – test

Annually

12-1998; 1-10.3.2

Clean agent system – inspection

Semi-annually

2001-2000; 4-1.3

Clean agent system – test

Annually

2001-2000; 4-1.1

Emergency   power generators

Inspection

Weekly

110-1999; 6-4.1

Battery electrolyte levels

Weekly

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; 3-4.4.1.1

Annual load test (if required)

Annually

110-1999; 6-4.2.2

3-Year 4-Hour load test

3-Years

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; 3-4.4.1.1

Medical   gas and Vacuum sys

Maintenance & testing

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

99-1999; 4-3.4.1.1

Cross-contamination test

After breaching of system

99-1999; 4-3.4.1.1

Purity and pressure test

After breaching of system

99-1999; 4-3.4.1.1

Alternative   Life Safety Measures

Policy

Review policy

101-2000; 4.6.10.1

Implementation

Review implementation documents

101-2000; 4.6.10.1

Fire Watch

Review fire watch documents

101-2000; 9.6.1.8 &   101-2000; 9.7.6.1

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

Annually

80-1999; 15-2.4.3

‘Exit’   signs

Illumination inspection

Monthly

101-2000; 7.10.9.1

Elevator   recall

Test of all elevators equipped with   Fire Fighter Service

Monthly

101-2000; 9.4.6

Fire   Drills

Healthcare occupancy

Quarterly on each shift

101-2000; 19.7.1.2

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Apr 24 2014

Documentation- Part 3: Sprinkler System

Category: BlogBKeyes @ 5:00 am
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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.

Device/Test/Inspection

Frequency

NFPA   Standard

Fire pump churn test

Weekly

25-1998; 5-3.2.1

Control valve inspection

Monthly

25-1998; 9-3.3.1

Fire department connections

Quarterly

25-1998; 9-7.1

Pre-action/Dry pipe valve priming   water test

Quarterly

25-1998; 9-4.4.2.1

Sprinkler inspection

Annually

25-1998; 2-2.1.1

Piping & hanger inspection

Annually

25-1998; 2-2.2

Pre-action/Dry pipe valve trip test

Annually

25-1998; 9-4.4.2.2

Main drain test

Annually

25-1998; 9-2.6

Control valve exercise

Annually

25-1998; 9-3.4.1

Backflow preventer

Annually

25-1998; 9-6.2

Anti-freeze test

Annually

25-1998; 2-3.4

Private service fire hydrants

Annually

25-1998; 4-3.2

Fire pump flow test

Annually

25-1998; 5-3.3.1

Occupant use fire hose – inspection

Annually

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

5-Years

25-1998; 9-4.2.1

Pressure gauge calibration

5-Years

25-1998; 2-3.2

Standpipe waterflow test

5-Years

25-1998; 3-3.1

Private fire service mains

5-Years

25-1998; 4-3.1

Internal inspection of system piping   (if obstruction conditions)

5-Years

25-1998; 10-2.2

QR sprinkler head replacement

20-Years

25-1998; 2-3.1.1

SR sprinkler head replacement

50-Years

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.

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Apr 17 2014

Documentation- Part 2: Fire Alarm System

Category: BlogBKeyes @ 5:00 am
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imagesT4IH0BMLThis is the second 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 presented some general suggestions on how to improve your documentation for easier retrieval during a survey. I suggested placing the test and inspection reports in 3-ring binders and separating them by categories. Use tabs to separate the categories so you can access the reports easier and faster.

The different categories that I present below are based on the Joint Commission Environment of Care standard EC.02.03.05; HFAP chapter 13 on Life Safety;  DNV PE.1, SR.2; and CMS Conditions of Participation. Here are the categories of the different test/inspection reports that you will likely need:

  • Fire alarm test reports
  • Sprinkler system inspection/test reports
  • Fire pump test reports
  • Alternative fire suppression test reports
  • Generator test reports
  • ATS test reports
  • Medical gas & vacuum system test reports
  • Interim Life Safety Measures assessments
  • Fire & smoke damper test reports
  • Fire door test reports
  • Exit sign inspection reports
  • Elevator recall test reports
  • Fire drills

Today I will identify what you need to have for a valid fire alarm test report.

Fire Alarm System

With the exception of the sprinkler water-flow switches, all of the other devices connected to the fire alarm system must be tested according to the frequency specified in NFPA 72 (1999 edition), section 7-3.2.  Water-flow switches must be tested according to the frequency specified in NFAP 25 (1998 edition), section 2-3.3. This list does not take into consideration any changes to testing frequency based on acceptance of the CMS Categorical waivers.

 

Device

Frequency

Initiating devices

Water-flow switches

Quarterly

Smoke detectors

Annually

Heat detectors

Annually

Duct detectors

Annually

Manual pull stations

Annually

Supervisory signal devices

Low air pressure   switches

Quarterly

Low water level   switches

Quarterly

Tamper switches

Semi-annually

Notification devices

Strobes

Annually

Horns

Annually

Bells

Annually

Chimes

Annually

Interface relays and   modules

Magnetic hold-open

Annually

Air handler shutdown

Annually

Kitchen hood   suppression

Annually

Elevator recall

Annually

Magnetic locks

Annually

Fire pump

Annually

Smoke dampers

Annually

Clean agent suppression

Annually

Sprinkler dry pipe

Annually

Sprinkler pre-action

Annually

Overhead rolling fire doors

Annually

Control panel batteries

Charger test

Annually

Discharge test

Annually

Load voltage test

Semi-annually

Smoke detector sensitivity test

2-years

Off-premises monitoring transmission equipment

Quarterly

 If you have these devices connected to your fire alarm system, then you need to have evidenced that each individual device was tested. That means you also need an accurate inventory of every device, complete with a description as to where it is located. The test report needs to list each and every individual device, a description of where it is located, and whether it passed or failed its test. This means there may be over 50 pages to an average test report since a typical 200 bed hospital may have over 2,000 devices connected to its fire alarm system.

Next week we will look at the sprinkler system.

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Apr 10 2014

Documentation – Part 1: General Suggestions

Category: BlogBKeyes @ 5:00 am
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images[4]

This is the first 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.

Surveyors and inspectors, whether they are from Joint Commission, HFAP, DNV, CIHQ, or your state agency surveying on behalf of CMS, all find it a bit frustrating when they have to wait and wait for hospital facility managers to dig through their piles of paperwork, looking for a specific test or inspection report. And making a surveyor frustrated is not a good thing during a survey.

I receive comments from surveyors all the time that they are astounded on how poorly organized some hospitals are when it comes to retrieving a specific report. Surveyors will cite an organization for non-compliance with a standard if the hospital cannot present the evidence to document that the test or inspection was completed. It doesn’t matter if the hospital actually performed the test or inspection if they cannot present the documents proving that it was completed.

A couple of hours of preparation prior to the survey can help make the whole documentation review process go a lot easier. This article (and subsequent articles on this same subject) will identify how you can organize your documentation so you can easily retrieve any test or inspection report that the surveyor wants to review.

I will post a new document review sheet titled “Acute Care Hospital Documentation Requirements” under my “Tools” page for you to down-load if you wish. That document is based on NFPA requirements for testing  and inspection, not necessarily what the accreditation organizations (AO) are enforcing. This is mainly due to the fact that the AO’s typically do not enforce everything that the NFPA codes and standards require.

General Suggestions

Suggestions on preparing your documentation:

  1. Put all inspection and testing work orders or contractor reports in a 3-ring binder, and categorize them by topic. Maintain the binders in an area where they are easily retrievable by anyone in event you are not onsite when the survey begins.
  2. You can have binders with multiple categories, or multiple binders with one category, whatever works for you. Since fire alarm test reports can be rather lengthy, they may deserve their own binder. Similarly, some contracted testing/inspection reports may be presented to you in their own binders.
  3. Each binder should reflect 1-years worth of documentation for that category, or one inspection/test if intervals are more than 1-year. For example, it doesn’t make sense to have a binder each year for fire & smoke damper testing when the test intervals is every 6 years for hospitals.
  4. Only include documents that actually demonstrate a test or an inspection. Do not include copies of invoices, purchase orders, or any other document that is not relevant for testing and inspection. All too often a hospital will present a purchase order or a contractor’s invoice as evidence that a life safety device was tested. That doesn’t prove the device was tested; only that you contracted to have it tested or you paid someone to have it tested. Do not add unnecessary information, such as a re-print of the standard that specifies the testing/inspection activities. The surveyors are not interested in that; they only want to see the evidence that the devices were tested or inspected.
  5. If a device was found to be defective or impaired during the testing/inspection activity, and it was not repaired/replaced the same day it was discovered, then make sure you have a copy of the Interim Life Safety Measures (ILSM) assessment document in the binder. All LSC deficiencies need to be assessed for ILSM when they cannot be immediately resolved. Having proof that you assessed the deficiency for ILSM in the binder next to the report, is a turn-key approach to managing the problem.
  6. If repairs or follow-up activities are required, then include copies of work orders, contractor test reports, or work tickets that demonstrate the device was repaired/replaced, and re-tested. You must be able to prove to the surveyor that the device was repaired or replaced, and that the repaired or replaced device was actually tested and it passed its test. Have a copy of this document stapled to the test report so you don’t have to spend time looking for it.
  7. Make sure the documents are legible… You may need to requests originals where carbonless copies are not readable.

Next week we will discuss what is actually required for an acceptable fire alarm test report, according to NFPA standards.

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Jul 26 2012

How Long Do I Need To Keep Documentation?

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I get asked this question from time to time…”How long must I keep test and inspections reports?” My answer has always been… Forever. Don’t throw anything out. You never know when you will need to prove something to your boss, a surveyor, or heaven-forbid, a lawyer.

At the hospital where I worked, early in my career I was either told by someone with more authority than me, or I just decided to do it, but I never threw anything out. I did clean out my files from time to time, but I would pack up the paper documents in boxes and hide them away in a crawl space in the hospital. It really wasn’t a secrete space, because every plant operator in the facilities department at one time or another crawled back into this area to service some air handlers. But it was pretty secure for my purposes, and the boxes were never removed, as long as I worked there. And there was more than one instance where I returned to the boxes to retrieve a document that proved to be rather valuable.

Now, I know Joint Commission says they want to see 12 months track record for testing and inspection on all fire safety systems, or back to the last cycle of testing, whichever is longest, but they have the right to look back even farther if they want. There have been multiple cases where surveyors found something that was suspect or wrong, such as a lack of proper main drain tests being conducted, and they traced back 3 years to see if the test was ever done successfully. This is ultimately helpful to the hospital as in many cases the organization can prove to the surveyor that the test was originally conducted but for whatever reason it wasn’t conducted at the time of the survey. This is helpful to prove to the surveyor that the test was inadvertently not conducted. If a surveyor found a history trail of a particular test not being conducted for many years, then they may cite the organization for non-compliance with the Centers for Medicare & Medicaid Services (CMS) Condition of Participation (CoP) 482.41, which requires the hospital to be maintained to ensure the safety of the patient. That is something you don’t want to happen.

I have been told by state agencies who perform validation surveys on behalf of the CMS that they want to see 3 years worth of testing and inspection documentation for all fire safety systems. It is apparent that depending on the state agency, they can and will hold you accountable for 3 years worth of tests and inspections.

So, the prudent thing to do is never throw anything out… just put it in a box and store it in a dry place. Being facilities people, we should know where all the ‘secrete’ storage spaces are located, and it doesn’t even have to be inside the hospital. Put it in the basement of the medical building down the street.

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