CMS has issued a blanket waiver for ITM

Updated on January 14, 2021

New Platform for Submissions of 1135 Waiver Requests and Inquiries 

In light of the volume of 1135 waiver requests associated with the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) has developed a new web-based tool located at CMS PHE Emergency Web Portal. The new tool is designed to reduce burden and streamline the submissions of 1135 waiver requests/inquiries in a simple-to-use format. It assists in expediting review of submissions, triages requests or inquiries, and tracks/reports on a national scale. The web-based platform is accessible via a PC or mobile device using Chrome or Firefox as your preferred browser. 

Updated on November 6, 2020

Are you one of the many health care organizations across the country that stopped life safety systems testing, inspections, and maintenance (ITM) because of COVID-19? Have you resumed routine ITM for your facilities yet or are you waiting until your state’s emergency declaration is lifted?

Let’s put this into perspective first. With a retroactive date of March 1, 2020 any missed ITM for life safety systems will not be cited during survey by an accrediting body until the day after your state lifts its emergency declaration or your organization declares that it is ready for survey. That’s correct! As of right now, other than the specific 1135 ITM waivers themselves, the Centers for Medicare & Medicaid Services (CMS) does not have any guidance for those health care systems that postponed or deferred ITM due to COVID-19. Nor have they included any grace period to provide health systems time to catch up. That’s not to say CMS won’t, but simply that they have yet to do so. 
 
Keep in mind that the 1135 waivers, were not issued until months after hospitals stopped conducting ITM. This fact should hopefully lead CMS to also allow a grace period should it issue any guidance.  

If your facilities are overdue for any ITM, your department needs to have a plan in place to be in compliance the day your state’s emergency declaration is lifted your incident command center is stood down or before either of these events.  Several elements of performance for life safety ITM, if neglected, could be cited as immediate threats to life and put your hospital in jeopardy. So it’s wise to be proactive and stay on top of ITM for these systems. 
 
Also, communicating with your incident command so that you are aware of the projected stand down date is vital to be able to properly coordinate the exact timing of deferred ITM.
 
ASHE’s COVID-19 Permanent Changes Task Force has created a checklist that can assist in not only coordinating when ITM needs to be completed, but also assist in properly documenting the deferral of and completion of ITM. The COVID-19 Recovery Checklist can be accessed below.
 

Updated on June 10, 2020

When will ITM under waiver need to be completed?

On April 21, 2020, CMS issued a blanket waiver that temporarily modified the inspection, testing and maintenance (ITM) provisions of the Life Safety Code (LSC) and Health Care Facilities Code (HCFC) to the extent necessary to permit health care facilities to adjust scheduled ITM frequencies and activities required by the LSC and HCFC. While this waiver is retroactive to the March 1, 2020, it is currently unknown when the waiver will be suspended. With some areas of the country starting their recovery efforts, it is time to consider how to address ITM efforts delayed under the waiver.

The ASHE COVID Recovery Team provided specific recommendations for documenting the adjustment of ITM schedules and provided a checklist for this documentation. For the ITM Checklist, along with all of the other recovery checklists, please access the ASHE COVID-19 Recovery webpage. 

The ITM Checklist provides columns to document the last date that the ITM was performed, when the waiver ended and when the ITM will be due. 

At this time it is unclear if CMS will provide any additional time after the state of emergency has been lifted. ASHE and accrediting organizations have requested that CMS provide an extension to the waivers past the lifting of the state of emergency so that ITM can be performed appropriately and thoroughly documented. 

In the ITM Checklist, the ASHE Recovery Team suggested timeframes for these extensions; however, since it is unclear if these will be acceptable to CMS, organizations may want to consider options that would allow the performance of these ITM efforts as organizations are recovering.

COVID-19 Recovery Checklist

Download

Updated on May 21, 2020

CMS has added an additional element to the 1135 waivers for the physical environment on May 20, 2020 since its first communication on April 30, 2020.

See pages 4-5 of the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers for details. In summary, the additional element states: 

CMS will permit facility and non-facility space that is not normally used for patient care to be used for patient care or quarantine, provided:

• The location is approved by the state.
• Use of the space is consistent with the state’s emergency preparedness or pandemic plan. This allows for increased capacity and promotes appropriate cohorting of COVID-19 patients.

The waiver update also notes that states are still subject to obligations under the integration mandate of the Americans with Disabilities Act, to avoid subjecting persons with disabilities to unjustified institutionalization or segregation.
 

Updated on May 14, 2020

CMS has added three additional elements to the 1135 waiver for the physical environment on May 11, 2020 since its first communication on April 30, 2020.

See pages 25-26 of the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers for details. A summary of the additional elements are:

Alcohol-Based Hand-Rub (ABHR) Dispensers:

• Waived prescriptive requirements for placement.
• Did not waive restrictions on location, storage and access.

Fire Drills: 

• Waived if a documented orientation training program related to the current fire plan, which considers current facility conditions, is implemented. 

Temporary Construction:

• Waived requirements that would not permit temporary walls and barriers between patients. 

April 30, 2020

CMS has issued a blanket waiver that temporarily modifies the inspection, testing, and maintenance (ITM) provisions of the Life Safety Code (LSC) and Health Care Facilities Code (HCFC) to the extent necessary to permit these facilities to adjust scheduled ITM frequencies and activities required by the LSC and HCFC. In relation to the templates for submitting inspection, testing and maintenance waivers to CMS there are several variances. Below is a listing of items that were either not included in the waiver issued by CMS or vary from the templates along with a comparison of these items based on the aforementioned templates:

Items not included in the CMS waiver:

• Sprinkler system monthly electric motor-driven and weekly diesel engine driven fire pump testing.
  • In the template these tests were not recommended to be deferred.
• Portable fire extinguisher monthly inspection.
  • In the template it was proposed that these inspections be deferred if outsourced but not deferred if the inspections were completed by in-house staff.
• Elevators with firefighters’ emergency operations monthly testing.
  • In the template it was proposed that these tests be deferred if outsourced but not deferred if the tests were completed by in-house staff.
• Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
  • In the template these tests were not recommended to be deferred.
• 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 the template these inspections were not recommended to be deferred.

In relation to the aforementioned templates for submitting inspection, testing and maintenance the CMS waiver would include the following:

• The requirement for testing of smoke and fire dampers has been waived.
  • In the template not deferment was proposed.
• The requirement for high-risk equipment PM has been waived.
  • In the template it was proposed that these PM’s not be deferred.
• Requirements for high risk utility system components PM have been waived.
  • In the template it was proposed that these requirements not be deferred.
• The requirements for appropriate pressure relationships, ACH, filtration, temp & humidity requirements.
  • In the template it was proposed that these requirements not be deferred.
• Requirements for infection control utility system components preventive maintenance.
  • In the template it was proposed that these requirements not be deferred.
• Requirement for the need of an outside window or outside door in every sleeping room has been waived.
  • This requirement was not listed in the template.

In relation to the previous templates for submitting inspection, testing and maintenance the CMS waiver does not address the following items:

• The requirement for sterilizer testing.
  • In the template it was proposed that these requirements not be deferred

For recommended time frame details on specific ITM items see the following updated waiver table:

Additionally, ASHE recommends that each organization evaluate the approved waivers and determine the appropriateness for their application at the organization. Those waivers that are determined to be appropriate should also be coordinated with the local and state authority having jurisdiction to obtain their approval.