CMS allows alternate preventive maintenance schedules

ISSUE BRIEF

January 7, 2014

The Centers for Medicare & Medicaid Services (CMS) recently issued a memo clarifying that hospitals may use alternative preventive maintenance schedules for most hospital equipment, clarifying a 2011 decision that required hospitals to follow manufacturer recommendations for many pieces of equipment. The change could be beneficial for many hospitals that feared sticking to manufacturer recommendations would take up more resources than necessary to keep equipment safe.

After CMS issued the 2011 memo, ASHE and other industry organizations met with CMS to discuss the issue. CMS issued another memo on Dec. 20, 2013, clarifying that hospitals could set their own alternative preventive maintenance schedules under certain circumstances.

CMS says hospitals that choose to use alternative maintenance activities or schedules must develop, implement, and maintain a documented Alternate Equipment Management (AEM) program to minimize risks to patients and others. The AEM program must be based on generally accepted standards, and CMS mentioned several examples of resources available to help hospitals set up AEM programs. For medical equipment, hospitals can consider using the American National Standards Institute/Association for the Advancement of Medical Instrumentation document ANSI/AAMI EQ 56:1999/(R) 2008: Recommended Practice for a Medical Equipment Management Program. For guidelines on physical plant equipment maintenance, consider the ASHE publication Maintenance Management for Health Care Facilities.

CMS notes that hospitals cannot use AEM programs when forbidden by other federal or state laws or other Conditions of Participation requirements. For example, all imaging and radiologic equipment must be maintained per manufacturer's recommendations. Hospitals cannot use AEM programs on medical laser devices and new equipment without a sufficient amount of maintenance history, CMS noted.

Key Points

  • CMS issued a memo on Dec. 20 clarifying that hospitals may use alternative preventive maintenance schedules for most hospital equipment.
  • The memo clarifies a 2011 decision that required hospitals to follow manufacturer recommendations for many pieces of equipment.
  • To use alternate maintenance schedules, hospitals must base the schedules on a risk-based assessment conducted by qualified personnel.
  • Certain pieces of equipment are exempt, including medical laser devices and new equipment that does not have an established maintenance history.

For more information, contact Chad Beebe, AIA, CHFM, CFPS, CBO, SASHE, director, codes and standards, at cbeebe@aha.org or 312-422-3824.