After several requests, CMS finally issued a waiver for some — but not all — equipment inspection, testing, and maintenance (ITM) requirements at hospitals and other healthcare facilities for the duration of the COVID-19 national emergency.
Critical systems for fire safety and other life-support systems are not part of the waiver, noted George Mills, the former director of engineering at The Joint Commission and now the CEO of AGT, a facilities management consulting company, via a LinkedIn post.
While CMS is relaxing some ITM requirements, check your local fire, health or building agencies having jurisdiction because they may not allow the waivers locally, notes William E. Koffel, P.E., FSFPE, SASHE, a former CMS surveyor and now president of Koffel Associates in a company blog post.
The blanket waiver was announced April 29 among several updates to previous waivers.
While the waivers will help lighten the load somewhat, the most critical and often the most time- and money-consuming of the ITM requirements are not part of the waiver.
The CMS summary of the relaxed rules notes specifically that these ITM requirements, which are identified as necessary under the NFPA 101-2012 Life Safety Code® and NFPA 99-2010 Health Care Facilities Code® and a part of Medicare’s Conditions of Participation (CoP), therefore are not included in the waiver:
- Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.
- Portable fire extinguisher monthly inspection.
- Elevators with firefighters’ emergency operations monthly testing.
- Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
- Means of egress daily inspection in areas that have undergone construction, repair, alterations or additions to ensure its ability to be used instantly in case of emergency.
What CMS is allowing hospitals, critical access hospitals, inpatient hospice, skilled nursing and nursing facilities, and intermediate care facilities is the flexibility “to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment,” in order to “reduce disruption of patient care and potential exposure/transmission of COVID-19.”
Some facilities have noted that many repair and maintenance companies have been reluctant to schedule regular inspections and maintenance for their equipment as hospitals have geared up to accept COVID-19 patients.
While the blanket waiver allows all hospital to relax the non-critical ITM activities, it doesn’t mean all facilities can or should, notes Koffel.
“It bears noting that the CMS waiver does not override local and state requirements. Most facilities are also required to comply with state or local fire codes which will also reference NFPA standards for inspection, testing, and maintenance,” wrote Koffel.
“Facilities should contact their respective Authority Having Jurisdictions (AHJ’s) to determine if they too will allow a deferral. It is recommended that you have a risk assessment prepared to submit to the respective AHJ’s.”
Accrediting organizations (AO), which are deferring most surveys during the national emergency, usually enforce CMS requirements and “will likely allow a similar modification to their accreditation requirements. While this blanket waiver is not identical to the waiver request submitted by The Joint Commission, it is similar in concept,” wrote Koffel.
Koffel also advises contacting your facility’s insurance carrier before adjusting ITM schedules. “Many commercial policies require compliance with NFPA standards.”
Note also that as with any of the blanket waivers, many consultants are advising facilities to:
- perform risk assessments
- clearly document why your organization used the waiver and how
- when your expected to resume normal activities
- and how you educated staff on the changes.
You should also stand prepared to defend your decisions with AOs do resume regular survey activities.
For a full rundown of the ITM physical environment waiver, see p. 23 of CMS’ April 29 updated summary of waivers.
For more on blanket waivers, see https://www.accreditationqualitycenter.com/articles/warning-despite-blanket-waivers-cop-emtala-regulations-are-still-effect.
A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.