How to Ensure Preventive Maintenance Compliance During a State of Emergency

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How to Ensure Preventive Maintenance Compliance During a State of Emergency

By Rick Joslin, Senior Advisor, Healthcare Strategy & Senior Solutions Architect, Healthcare

Given the current COVID-19 pandemic, every faction of healthcare operations is being pushed to unprecedented levels.

Tough decisions are being made about what activities must be done and what can wait. For instance, planned maintenance and repairs on critical equipment are being prioritized over all other work. The challenge is that healthcare regulations are very specific and rigid around most maintenance and service activities. 

By employing the following tactics, healthcare delivery organizations can not only position themselves to meet the demand and stay in compliance with regulatory requirements during this crisis but will also save time and resources in the future.

Alternate equipment management (AEM) program tactics.

A proven and regulatory compliant way to lighten the preventative maintenance (PM) workload is to implement an AEM program. The Centers for Medicare & Medicaid Services (CMS), in their publications S&C 14-07 (for hospitals) and S&C 14-41-CAH (for critical access hospitals), allow hospitals to “adjust its maintenance, inspection, and testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment by qualified personnel.” After many decades of simply following manufacturer recommend procedures, this provided a method to reduce or eliminate unnecessary preventive maintenance (PM) activities and regain resources for use elsewhere. 

An AEM program could result in a 20%-50% gain in resource availability for other activities. In this pandemic crisis, even a 20% increase in available resources could be the difference in meeting the service demands and failing to meet them. If your organization does not have an implemented AEM program, you should plan to begin implementation as soon as possible.

Requesting 1135 waivers.

When the President of the United States declared a national emergency for the COVID-19 outbreak, it put in motion the opportunity for healthcare organizations to request waivers of compliance for many regulatory requirements. These waivers are classified as “Section 1135 Waivers” and can be used to defer some activities required by CMS Conditions of Participation (CoPs). For example, a waiver request of The Joint Commission scheduled maintenance requirements under EC.02.04.03 EP3 and EC.02.05.05 EP6 would allow an organization to defer PMs on non-high-risk equipment for up to 60 days after the lifting of the state of emergency. 

With this single waiver an organization could realistically shift 20%-30% of their expected PM resource needs to COVID-19 or other activities.

There are several areas where waivers can be requested: 

  • Conditions of participation or other certification requirements (PM and other activities).
  • Program participation and similar requirements.
  • Pre-approval requirements.
  • Emergency Medical Treatment and Labor Act (EMTALA).
  • Stark self-referral sanctions.
  • Performance deadlines and timetables may be adjusted (but not waived).

There are several places where an organization can obtain more information on 1135 waivers and what can be requested: 

It’s highly recommended that you pursue this avenue to allow your team to focus on the necessary activities in support of their organization’s COVID-19 response. Waivers are also backward-compliant to March 1, 2020 to ensure all activities altered since then are documented and available if needed.

Exploring temporary compliance options.

As noted in our previous blog post, Effective Planning for COVID-19 Occupancy Changes, you must connect with your local and state authorities having jurisdiction (AHJs). These individuals and organizations are the key to ensuring anything you do meets their compliance requirements.  

Use common sense in your planning and execution. The ultimate goal of any activity is a safe environment for patients and staff. If you can’t have the proper fire safety precautions in place, then implement Interim Life Safety Measures. All non-compliant activities must be documented to indicate what was altered, why, when and under whose authority. Don’t forget to reference any regulatory statute as well to help with reporting needs. 

Some regulatory agencies are publishing guidance on ways to meet the emergency response needs while maintaining a safe and compliant environment.

The National Fire Protection Association (NFPA) has issued documentation in support of healthcare organizations’ efforts to create the additional treatment space needed for the tremendous influx of patients:

CMS has several web sites dedicated to helping healthcare organizations during this crisis:

Understanding occupancy regulations for healthcare institutions.

Healthcare organizations must continue to provide safe and operational equipment and spaces for patient treatment. Having the flexibility to defer a portion of your required PM activities for several months could provide the lifeline you need to align your limited resources with critical patient services. Using the references above, your organization can achieve stellar performance during this national pandemic crisis.

Accruent Healthcare is offering FREE COVID-19 tools to help healthcare organizations respond. Visit our COVID-19 special reports from Accruent Healthcare page to learn more.


About the Author

For more than 18 years with Accruent, Rick Joslin has helped healthcare systems navigate the ins-and-outs of managing maintenance activities within their organizations. With over 30 years in maintenance management industry, at levels from technician, to director, to inspector/compliance surveyor, he is known for promoting continuous improvement, driving operational efficiency, increasing resource utilization, and ensuring regulatory success. As the Senior Advisor, Healthcare Strategy and as a Senior Solutions Architect, Healthcare, Rick leverages LEAN thinking and Six Sigma processes to guide our customers in the development of short- and long-term goals for measurable, continuous results across a wide variety of healthcare environments, while also helping them to identify gaps and inefficiencies in business processes and driving operational excellence. His broad knowledge of Healthcare operations and regulatory requirements, coupled with an intimate knowledge of the TMS systems, allow him to assist customers in developing easily-implemented solutions to unique, and changing, business needs.

Using Managed Services, and putting the administrative needs for utilizing Accruent Professional Services personnel on a fast-track, Rick can assist your organization to quickly identify opportunities for operational improvements, automation for repetitive processes, KPI and metrics analysis, and resource utilization enhancements.

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