Here are some of the things you should consider before locking the door behind you.

During these times of uncertainty, many facilities are contemplating closure.  Taking the proper steps in closing can be pivotal to your ability to reopen timely.  To help you with this process, we at CE-Tech have put together a list for which you can consider. Reopening will most likely be a spontaneous event, so ensuring proper operation of systems and equipment is essential to getting back to business as normal.

Under guidance from CMS (see CMS Memorandum QSO-20-20-All ) , approved accreditation agencies are limiting surveys for the time being. Most may agree that there is a possibility of leniency relative to the Coronavirus pandemic. However, CMS has not hinted at any. So, what you do now and how you prioritize inspections that are required during your scheduled closure is your road map for compliance in the future.

If you have outsourced to a reputable vendor, ask them what is due and the frequency in which it is scheduled (including dates ) . If you are temporarily closing for a few weeks, you should continue the required inspections. If you are closed for a longer spell, you’ll need to know what needs to get done immediately upon reentering the building. It’s important to not only know what inspections might get overlooked but to asses them and have a plan of action justifying potentially skipping it. Take for instance a scheduled drill. How would you document the required event if you’re closed?

A quality vendor will have reports that can be used to assess your Life Safety, Facility Management & Biomedical PM’s and inspections. Consider weekly, monthly, quarterly, semi/annual and beyond. Depending on your situation, prioritize and plan to do those that are most important in securing the facility and maintaining a level of safety. At a minimum, ALL fire-related tests and inspections should be performed as well as the emergency generator.

Make a checklist for what needs to be done prior to closing the door in order to pick up where you left off when you return. Inspect the physical plant and verify the functionality of all building systems and emergency systems. Prepare daily (preferred ) or weekly (minimum ) scheduled walk thrus. Check for alarms, leaks, unusual noises, broken or nonfunctional equipment (you’d be surprised what breaks when no one’s even around ) . If required, document Freezer temps and humidity as well. Remember that compliance documentation is just as important on the day you reenter the facility as it is when you are fully operational.

For extended closures, make decisions on shutting systems down. What are you going to do with HVAC, MedGas, Steam, Alarms, etc. Perform risk assessments to identify critical medical equipment, utility systems, and operating components. Realizing it can be overwhelming, especially if it is not something you are used to doing, we are provided the following list of reminders for you to consider before you close the door. Click here for a downloadable version of this checklist.


– Have a contact list of all vendors in case of an emergency.

– Assign responsibility for the monitoring of refrigeration temperatures, medical gas master alarm, fire alarm panel, generator panel, and refrigerator temperatures.

– Notify vendors of the temporary closing and adjust delivery, pick-up, or services. (med gas, bio-hazard, linen, mail, etc. )

– Assign periodic inspection for water leaks, theft, electrical issues, storm damage, etc.

– Ensure the Fire alarm monitoring company has a good number for emergency contact


– If breakers are turned off, ensure those to emergency” red” outlets are ON

– Ensure medical refrigerators and other sensitive equipment are plugged into red outlets

– Do not shut off any Life Safety breakers (LS panel )


– Consider boiler shut down


– Check condensate pans for proper drainage.

– Check exhaust systems (functioning, belts, etc. )

Life Safety

– Schedule maintenance and testing of systems and equipment including:

– Fire alarm transmission

– Generator (weekly and monthly runs )

– Transfer switch exercise

– Line isolation monitor test (monthly )

– Emergency battery lights (monthly )

– Nurse call (monthly )

– Fire extinguisher (monthly )

– Eyewash (weekly )

– If an inspection (fire alarm, sprinkler, generator, bio-medical testing, etc ) is scheduled during your closing, ensure someone is available to allow access to stay compliant with regulations.


– Check all exterior doors and windows for proper latching and locking.

– Ensure security alarm transmission to the provider.

– Security of medical equipment and PPE

Medical Gas System

– Ensure security from theft and mechanical damage

– Vendor pick-up of “empty” cylinders

– (Suggested ) – Shut off all H-tanks except one to the manifold and monitor master alarm weekly.

– Shut down of Vacuum pumps

Remember, CMS requires various types of compliance documentation be ready and easily retrievable at any time. Doing the required inspections are only half of the process. Documenting each inspection is the other half. The old adage, “the works not done until the paperwork is complete” certainly plays here.

Additionally, locating and securing documentation prior to closure will make it much easier to reopen. As a guide for what document types are required, we have listed them here:

  • Project record documentation such as test and inspection reports, permits, licenses, certifications, documentation of all required “testing prior to initial use” and AHJ approvals.
  • Documentation for the facility such as inventories, management plans, P&Ps, risk assessments, training records, maintenance decision processes, inputs into P&Ps and maintenance management systems from operation and maintenance (O&M ) manuals, evaluations, lists, spreadsheets, databases, schedules, and forms for ongoing required drills, exercises, tests, inspections/maintenance, and all required emergency operations plan (EOP ) documentation.
  • Records regarding the Life Safety Assessment and accurate updated Life Safety plans, electronic statement of conditions.
  • Documentation related to PPE, spill kits, monitoring equipment, and other supplies.
  • Mapping of utility systems and labeling for critical utility disconnects.

In conclusion, no matter whether you plan to close temporarily or long term, it is imperative to maintain the building and critical systems while vacated. Performing frequent walk thrus and inspections is a must. Having up to date documentation and knowing where it is located will help get things moving quickly once you’ve reoccupied. The real key is taking the time to do these things before you leave so you can get up and running later with far less anxiety and work to do. The more you do before, the better it will go after.

CE-Tech Disclaimer

This blog provides general information and discussions about Healthcare Technology related subjects. The content provided is not intended to be a substitute for the advice of service providers or authoritative bodies in the Healthcare Technology field.