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.