by Brad Keyes, CHSP, on Jan 18, 2021 1:00:00 AM
Q: We have a brand new free-standing patient tower addition to our hospital coming online and scheduled to open in 12 months. The contractors will be performing PM's on the boilers, generators, etc. until the building is turned over to the hospital. At what point will CMS and the accreditation organization expect us to begin documentation of all required PM's and testing - at the moment the equipment is certified and brought online, or once the equipment is handed over to the hospital months later? I believe the answer is once the equipment is brought online, but our contractor disagrees.
A: This is not a clearly defined subject, so initially, let me say you should contact your accreditation organization and ask them.
But it makes sense to me that the PM expectations should begin when the mechanical systems are turned over to you, not when they are installed. The expectation is when the mechanical systems are turned over to you, the contractors will have provided certification reports that the systems are functioning properly. These reports are essentially the same as your annual test reports, such as fire alarm test reports and sprinkler system test reports. It is perfectly normal for a surveyor to expect you to provide documentation that each and every device was tested and inspected in accordance with NFPA standards during the initial visit.