During this period of COVID-19 crisis, many readers have written asking if they can discontinue conducting routine Life Safety tests and inspections in order to limit service technicians from entering the building and to suspend fire drills to allow staff to focus on patient care and the pandemic emergency. The response from this website has been consistent and focused on the CMS Condition of Participation (Condition for Coverage for Ambulatory Surgical Centers) that regulates nearly all of the non-government healthcare facilities: Until such time CMS (or your accreditation organization) makes an announcement regarding changes in required tests, inspections, and drills, the answer is no, you may not. You still have to conduct all of the required tests, inspections, and drills that are required in the Life Safety Code.
But there is a glimmer of hope on this subject. When CMS issued its Final Rule on Emergency Preparedness on September 16, 2016, they explained that there is available for healthcare providers an 1135 waiver process that allows the healthcare organization to not have to meet certain CMS standards during a declared emergency. What is unclear, if the 1135 waiver process applies to the testing, inspecting and fire drill requirements.
Accreditation organizations, member organizations, and this website have written CMS asking them if the 1135 waiver process would apply to the required testing, inspection and fire drills found in the Life Safety Code. So far, CMS has not replied to any of those who have inquired.
But the American Society for Health Care Engineering (ASHE) issued a communication to its members on Friday, April 3, 2020, providing instructions on using a template for a letter that you can send to the appropriate CMS Regional Office asking for specific 1135 Waiver exemptions on testing, inspections, and fire drill requirements. While this 1135 Waiver letter can only help the situation, it is important to understand that as of today, CMS has not indicated that suspension of testing, inspection, and fire drills is permitted under the 1135 Waiver request.
With the approval from ASHE, we are providing a couple of link connections to their webpage that explains the 1135 Waiver process and the template letter:
We repeat ASHE’s introductory paragraph for this 1135 Waiver in case you missed this important information:
Health care facilities can access a templated letter and table to request a waiver under Section 1135 of the Social Security Act. The waiver will allow facilities to delay inspection, testing, maintenance and certain drills required by the Centers for Medicare & Medicaid Services. The letter must be modified to include the health care organization’s information. The table, which should be submitted with the letter, gives guidance on how requirements should be modified during the COVID-19 emergency. Waivers help to limit non-essential persons from entering health facilities and risking exposure, while also allowing health care staff to focus on patients.