CMS Memorandum Dec 20, 2013 Hospital Equipment Maintenance Requirements
Posted on Jan 23, 2014
• S&C 12-07-Hospital Superceded: We are updating previously provided guidance to
o Hospital facilities, supplies and equipment must be maintained to ensure an acceptable
level of safety and quality.
o A hospital may adjust its maintenance, inspection, and testing frequency and activities
for facility and medical equipment from what is recommended by the manufacturer,
based on a risk-based assessment by qualified personnel, unless:
• Other Federal or state law; or hospital Conditions of Participation (CoPs) require
adherence to manufacturer’s recommendations and/or set specific requirements.
For example, all imaging/radiologic equipment must be maintained per
manufacturer’s recommendations; or
• The equipment is a medical laser device; or
• New equipment without a sufficient amount of maintenance history has been
• Hospitals electing to adjust facility or medical equipment maintenance must develop
policies and procedures and maintain documentation supporting their Alternate Equipment
Management (AEM) program. They must adhere strictly to the AEM activities and/or
frequencies they establish.
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