• In accordance with 42 CFR 485.623(b)(1), CAHs are required to maintain all essential mechanical, electrical and patient-care
equipment in safe operating condition.
o A CAH 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, unless:
• Other Federal or state law, or CAH Conditions of Participation (CoPs) require adherence to manufacturer’s recommendations
and/or set specific requirements. For example, the National Fire Protection Association (NFPA) Life Safety Code (LSC) requirements
incorporated by reference at 42 CFR 485.623(d) have some provisions pertinent to equipment maintenance, and compliance with
these requirements is assessed on Federal surveys; or
• The equipment is imaging/radiologic equipment or a medical laser device; or
• New equipment without a sufficient amount of maintenance history has been acquired.
• CAHs 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
• CAHs must be able to demonstrate that qualified personnel, whether employees or contractors, are making the decisions to
place equipment in the AEM program, performing the risk-based assessments, establishing the alternate equipment maintenance
requirements, managing the AEM program, and performing the maintenance in strict accordance with the AEM policies and procedures.