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.

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.

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 1: General Suggestions


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.

How Long Do I Need To Keep Documentation?

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.