Documentation – Part 1: General Suggestions

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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.