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What you should know about documenting medical maintenance

April 03, 2014
Dale Hockel
From the April 2014 issue of HealthCare Business News magazine

By Dale Hockel

Understanding and achieving regulatory compliance can be a daunting, but a necessary task. Rigorous requirements from the Centers for Medicaid & Medicare Services, accreditation requirements, state department of health compliance, and recalls/ alerts from the FDA and OEMs demand a full-time professional to understand all standards and regulations for every device in a hospital. Instead, many hospitals rely on already taxed clinical engineers to do the job. Although capable, CEs lack the time required to effectively engage with each regulatory body or stay current with every device.

Let’s examine a few regulatory requirements for documenting medical maintenance and determine if you have compliance covered.

A Plan
Compliance starts with a medical equipment management plan. A MEMP includes the following:

  • Written plan and supporting policies and Procedures

  • Process of selecting, planning, acquiring equipment

  • Process of addressing equipment use errors and patient risks

  • Preventive Maintenance of life and non-life support equipment and documentation

  • Maintenance strategies and intervals
  • Alerts, recalls

  • Safe Medical Device Act requirements

  • Process for evaluating effectiveness

The MEMP starts with accurate inventory management — knowing what you have, its PM schedule, how it’s utilized, etc. Not knowing this critical information puts you and the facility at risk. The regulations state:

1. CMS Regulations 482.53 “An equipment inventory and incident history is maintained.”

2. The Joint Commission, EC02.04.01, EP2 “The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment … and equipment incident history.” Regulations require hospitals to establish a precise inventory of all medical equipment and to document maintenance and PM regardless of ownership. Although regulatory bodies do not specify how the inventory is documented, the best practice is a computerized maintenance management system that stores information in one location, allows you a complete list of inventory and its history on file, and is easily accessible.

Preventive Maintenance
The next important step to staying compliant is the management of PM frequencies. The regulations state:

1. The Joint Commission, EC02.04.01, EP3 & EP4 “The hospital identifies the activities, in writing, for maintaining, inspecting and testing for all medical equipment on the inventory. The hospital identifies in writing, frequencies for inspecting, testing and maintaining medical equipment on the inventory based on criteria such as manufacturers’ recommendations, risk levels or current hospital experience.”

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