How Long Do I Need To Keep Documentation?
by Brad Keyes, CHSP, on Jul 26, 2012 12:00:00 AM
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.