Should discontinued and/or revised policies still be maintained by the facility?


It is always best to check with your facility legal counsel for their guidance on what documents, other than resident care records, should be maintained, where to maintain them and for how long.  It is usually recommended that you keep discontinued and/or revised versions of policies in a secured electronic location that cannot be accidentally accessed and used by staff. Surveys and lawsuits can (and often will) occur an extended period of time after an event/incident has occurred and the related policy has been discontinued and/or revised.  You want to be able to show the policy that was in effect at the time of the event/incident, rather than what is addressed in the current policy.   When being investigated in a survey or lawsuit, you must be able to substantiate that you adhered to the stipulations of the policy in place at the time of the event/incident.  If you do not maintain these older policy versions, it will make substantiating this much more difficult, if not impossible.  For this same reason, it is recommended that policies include the date of the revision in order to clearly identify when they went into effect.

Janine Lehman, RN, RAC-CT, CLNC Director of Legal Nurse Consulting

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