A historical area of compliance challenges, related to hospital construction/renovation projects, may be getting worse.  Many organizations have struggled with obtaining timely receipt of details relating to new utility system components as well as manufacturer’s operating and maintenance manuals.

The CMS December 2013 Alternate Equipment Management changes (related TJC July 2014 Alternate Equipment Maintenance changes), that we have written about several times in the past year, have raised the bar on compliance related to equipment inventories as well as inspection, testing, and maintenance (ITM) activities.

Maintaining accurate inventories has always been a requirement, but with the likely increased survey focus in 2015 and 2016 there may well be a higher risk of adverse survey findings.

CMS and TJC require complete inventories of all utility system equipment (TJC’s EC.02.05.01 EP-2 states “The hospital maintains a written inventory of all operating components of utility systems.”)

CMS and TJC require that all critical equipment (which TJC calls “high-risk operating components” in EC.02.05.01 EP-3) be clearly identified within the inventory.  This requires that the related risk assessment be completed and its results documented.

Both organizations require that all ITM activities and associated frequencies be identified in writing for all equipment on the inventory.  These activities and frequencies must comply with applicable codes, standards, and regulations, of course.  They must also comply with the manufacturer’s recommendations or with the strategies of the organization’s Alternate Equipment Management/Maintenance (AEM) program, provided that the AEM program itself complies with the detailed AHJ requirements.

A comprehensive risk assessment process (which we will call the AEM risk assessment) is required before the organization decides that any components may be managed in accordance with the AEM program.  We wrote about this risk assessment in our March 2015 Compliance News post.  It takes time to complete, particularly when numerous new inventory items are to be considered.

Both organizations require that the organization have a copy of the manufacturer’s ITM recommendations and use that information in developing the ITM processes, whether those processes are the manufacturer’s recommendations themselves or approved variations based upon the AEM program.  Not all construction/renovation project record document submittals contain the required information.  They should be discussed with equipment manufacturers, contractors, and subcontractors proactively to make sure that they are not simply a rehash of the shop drawing submittals.  Both CMS and TJC require that the organization have a timely set of manufacturer’s inspection, testing and maintenance recommendations to use when setting up the associated ITM processes.

You may contact the writer at DStymiest@ssr-inc.com if you have questions on this content.