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CMS Revises Communication on 1135 Waivers

by Brad Keyes, CHSP, on May 12, 2020 1:00:20 AM

As reported on this website last week, CMS issued a formal communication on April 29, 2020, that granted 1135 blanket waivers on Physical Environment items for Inspection, Testing & Maintenance (ITM). CMS is temporarily modifying its Conditions of Participation (CoP) requirements to the extent necessary to permit healthcare facilities to adjust scheduled inspection, testing, and maintenance frequencies and activities for the facility and medical equipment.

In the April 29, 2020 communication, CMS stated the following NFPA 101-2012 Life Safety Code (LSC) and NFPA 99-2012 Health Care Facilities Code (HCFC) ITM are considered critical and 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 minutes of 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 a revised communication on the 1135 waivers issued May 8, 2020, CMS is modifying (and clarifying) the following requirements:

  • Alcohol-based Hand Rub (ABHR) Dispensers: CMS is waiving the prescriptive requirements for the placement of ABHR dispensers for use by staff and others due to the need for the increased use of ABHR in infection control. However, ABHRs contain ethyl alcohol which is considered a flammable liquid, and there are restrictions on the storage and location of containers that must be adhered to.
  • Fire Drills: Due to the inadvisability of quarterly fire drills that move and mass staff together, CMS will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures, and fire protection devices in their assigned area.
  • Temporary Construction: CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients.

To review the actual revised CMS communication, click on the following link and examine pages 24 - 26:


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