With many questions surrounding the inspection, testing, and maintenance of equipment and life safety systems during the COVID-19 pandemic; we would like to encourage you to continue to maintain a safe environment for your staff, patients, and visitors alike. Thus far CMS has not issued a blanket waiver for ITM and has left the decision up to the individual states.

Through our relationships with The Agency for Healthcare Administration (AHCA ) we understand they are prepared to release this statement.

“Due to the COVID 19 Public Health Emergency facilities are required to prohibit visitation for the next 30 days. During this period of time The Agency of Health Care Administration Field Operations will allow an extension for Life Safety test requirements that are due and performed by vendors. For in-house testing of emergency lighting, generators and any other system that are routinely performed by your staff are still required. This is to ensure your facility remains safe for your residents and staff. In some situations like your hood cleaning and inspection this can be done without putting anyone at risk. Facility staff are required to monitor all the life safety systems to ensure their working properly, we will revisit this situation in mid-April.”- AHCA Representative

For the state of Florida, we can conclude at this time that properly maintaining equipment and life safety systems to the AHCA standard is a requirement, regardless of whether you’re open or closed due to COVID-19. However as suggested by this statement, due to the mandatory 30 day no visitation rule an extension will be given for any testing that is required to be performed by vendors.

Rescheduling of these inspections should be made immediately after the 30-day visitation restriction. The expectations of all other ITM that is routinely performed internally will remain for the time being.  If your facility has closed during this time, the expectation for compliance still remains.

Surveys from CMS/AHCA/accrediting agencies remain prioritized to:

  • All immediate jeopardy complaints (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death or harm ) and allegations of abuse and neglect;
  • Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses;
  • Statutorily required re-certification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities )
  • Any re-visits necessary to resolve current enforcement actions
  • Initial certifications
  • Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years;
  • Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy.