A Brief AEM Overview
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by David Stymiest, P.E., CHFM, CHSP, FASHE
Senior Consultant, SSR
CMS changed the long-used rules for both inventories and equipment inspection, testing and maintenance (ITM) requirements in December 2013. The CMS changes require that, where law and regulations do not stipulate ITM, manufacturer ITM recommendations must be followed unless the organization has a compliant AEM Program and uses a risk-based process to determine how and when to deviate from manufacturer ITM recommendations.
Many existing hospital AEM Programs are not fully CMS-compliant. Other hospitals hesitate to establish an AEM Program simply because of the paperwork involved, including the CMS-required risk assessments that differ substantially from previous practices. This hesitation blocks cost-effective decision making based upon perfectly acceptable long-term hospital experience.
The CMS-issued Survey & Certification (S&C) Letter S&C:14-07-Hospital (entitled Hospital Equipment Maintenance Requirements) dated 12/23/2013 includes both the requirements and 11 pages of state survey agency interpretive guidelines. That CMS S&C Letter is available at http://tinyurl.com/CMS-AEM-PDF. It should be required reading by those responsible for hospital equipment ITM.
An AEM Program must be CMS-compliant to be acceptable. Setting up the AEM Program is challenging at first. However, the challenge gets easier once the hospital understands how the CMS requirements can be met based upon a long history of acceptable hospital operation.
Two detailed white papers on AEM and related requirements are available from the writer by emailing DStymiest@ssr-inc.com:
- AEM Program Compliance (originally delivered at the 2015 ASHE Annual Conference)
- AEM Risk Assessments (originally delivered at the 2016 ASHE Annual Conference)
