Focus: Fire-Life Safety / Column

Regulations, Codes & Standards Q&A: Corrective Maintenance Work

By Brad Keyes / Special to Healthcare Facilities Today
November 4, 2020

Q: Thanks for all the great information that you provide; it is very helpful! I just have a quick question about corrective maintenance work orders. Do you know how many days a mechanic has to make repairs when the PM/equipment fails?

A: There are no set standards on how many days a technician may take to resolve a defective piece of equipment. In regards to a survey, CMS does have standards that say no more than 60- days are permitted to resolve deficiencies identified by a surveyor during a survey (an accreditation survey or a CMS validation survey), but that is not quite the same as a routine non- survey fix and repair situation. CMS also says if a particular LSC deficiency requires more than 60-days to resolve (i.e. time to design, competitive bidding, delivery lead-time, availability of space, etc.), then the organization may submit a Time-Limited Waiver request as part of their Plan of Correction to request more than 60-days to resolve an issue.

The expectation is the organization will take appropriate and immediate action to resolve all deficiencies, and when they cannot be resolved the same day they are discovered then an ILSM assessment must be conducted.

Brad Keyes, CHSP, is the owner of KEYES Life Safety Compliance, and his expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs.

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