In the grand scheme of things, this helps—but how much?

By Steve MacArthur, Hospital Safety Consultant

A few weeks back we chatted about efforts to engage the 1135 Waiver process as a function of fire and life safety systems inspection, testing and maintenance, particularly as a function of ASHE’s efforts to facilitate a coordinated response. Apparently, this part of the waiver picture was not a priority for the folks at regional CMS, so there were a number of rejection notices sent to folks.

I’m not exactly sure what may have transpired (other than the passing of time, but if there were folks with access to CMS ears that continued to advocate, a debt of gratitude is owed), but some items related to certain inspection, testing & maintenance activities have finally made it to the slate of blanket waivers. You can find the information here, on page 23 of the linked document. Unfortunately, it appears that the blanket waiver announcement is being released in cumulative form, so you have to dig a little bit to find the applicable passage. Because of that, I’ve copied and pasted the information below.

As near as I can tell, the areas of greatest concern for the moment are those activities for which waivers were not granted:

• 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.

In looking at the list, I think that it is both reasonable and very practical from a safety perspective. Clearly, as busy as it is, there are critical processes/protections that need to be assured, so hopefully you haven’t missed any of those noted activities and, if you have, you probably need to start working on preparing your organizational leaders for some likely survey findings.

As a closing thought, lately while walking I’ve been checking out some new (to me) podcasts, one humor-based (Conan O’Brien Needs A Friend—generally pretty good—a couple of good “laughs out loud” per episode) and one not so much so, which is my shareable moment for you. Lately, the Freakonomics Radio podcast has been covering subjects relating to the pandemic, with the episode I listened to today being “How Do You Reopen A Country?” One of my favorite aspects of this program is their tendency to come at topics in a calm, measured fashion, but generally from a somewhat unusual angle, but I don’t want to spoil it for you be jabbering too much. If you’re interested in something thoughtful, but not crazily scary, you might enjoy the episode.

Hope this finds you safe and well – until next time…

CMS Blanket Waiver Information

Inspection, Testing & Maintenance (ITM) under the Physical Environment Conditions of Participation: CMS is waiving certain physical environment requirements for Hospitals, CAHs, inpatient hospice, ICF/IIDs, and SNFs/NFs to reduce disruption of patient care and potential exposure/transmission of COVID-19. The physical environment regulations require that facilities and equipment be maintained to ensure an acceptable level of safety and quality.

CMS will permit facilities to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment.

• Specific Physical Environment Waiver Information:

o 42 CFR §482.41(d) for hospitals, §485.623(b) for CAH, §418.110(c)(2)(iv) for inpatient hospice, §483.470(j) for ICF/IID; and §483.90 for SNFs/NFs all require these facilities and their equipment to be maintained to ensure an acceptable level of safety and quality. CMS is temporarily modifying these requirements to the extent necessary to permit these facilities to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment.

o 42 CFR §482.41(b)(1)(i) and (c) for hospitals, §485.623(c)(1)(i) and (d) for CAHs, §482.41(d)(1)(i) and (e) for inpatient hospices, §483.470(j)(1)(i) and (5)(v) for ICF/IIDs, and §483.90(a)(1)(i) and (b) for SNFs/NFs require these facilities to be in compliance with the Life Safety Code (LSC) and Health Care Facilities Code (HCFC). CMS is temporarily modifying these provisions to the extent necessary to permit these facilities to adjust scheduled ITM frequencies and activities required by the LSC and HCFC. The following LSC and HCFC ITM are considered critical are not included in this 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.

o 42 CFR §482.41(b)(9) for hospitals, §485.623(c)(7) for CAHs, §418.110(d)(6) for inpatient hospices, §483.470(e)(1)(i) for ICF/IIDs, and §483.90(a)(7) for SNFs/NFs require these facilities to have an outside window or outside door in every sleeping room. CMS will permit a waiver of these outside window and outside door requirements to permit these providers to utilize facility and non-facility space that is not normally used for patient care to be utilized for temporary patient care or quarantine.

About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is also a contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.