Maintenance Department staff are the spark plugs and oil of the facility engine.  Without an operational physical plant and working equipment, the facility could not “drive” quality in all other departments. How effectively are you ensuring proper Care and Maintenance of the Maintenance Department? Consider these opportunities for keeping the Maintenance Department engine fired up with regards to survey readiness, safety and equipment monitoring.

The Maintenance Department staff are the front line for ensuring compliance with the Environmental and Life Safety Regulatory Requirements. They must be vigilant in identifying issues with the facility structure, utilities and safety features, such as fire safety protections.  The top 6 cited deficiencies in 2022 for maintenance include:

      • F 584 Safe/Clean/Comfortable/Homelike Environment
      • F921 Safe/Functional/Sanitary/Comfortable Environment
      • F925 Maintains Effective Pest Control Program
      • F919 Resident Call System
      • F700 Bedrails
      • F908 Essential Equipment, Safe Operating Condition

The top 6 cited Life Safety Code issues for 2022 include:

      • K353 Sprinkler System – Maintenance and Testing
      • K918 Electrical Systems – Essential Electric System
      • K321 Hazardous Areas – Enclosure
      • K363 Corridor – Doors
      • K345 Fire Alarm System – Testing and Maintenance
      • Fire Drills

The Maintenance staff must monitor the facility interior and exterior as well as the equipment being used, for any repairs, replacements or updates.  The use of a daily Preventive Maintenance Checklist or the CMS Critical Element Pathway #20061 Environmental Observations found in the survey resources at: can assist the Maintenance staff in determining the observations and evaluations that must be completed routinely.

Creative Ideas to Tackle Facility-Wide Maintenance Activities

There are numerous maintenance tasks that must be completed each day. One of the most important to the safety of the residents maintaining mobility items in top condition. Mobility equipment checks can be difficult to complete when these items are typically in use during the day. A creative way to provide an access opportunity for maintenance to complete a “check-up” of resident wheelchairs and walkers is to hold a Wheelchair/Mobility Device “Tune Up” Clinic. This event can involve all facility departments and involve a fun (and productive!) day of activities for the residents and staff. Activities can develop a theme, put up signs/decorations and give out “appointment cards” to the residents for the time they can bring in their “vehicle” aka wheelchair or walker, for inspection.  Dietary can provide snacks and drinks at the “auto-shop” location, which could be decorated with various auto garage type items. The nursing staff can escort the residents to and from their appointments, and perhaps join activities to provide some “car-themed” musical entertainment while they wait.

      • Housekeeping may take the opportunity to clean equipment.
      • Maintenance staff may perform preventive inspections during the clinic with minor adjustments made on-site and creating a work order to follow up on any needed repairs or replacements.
      • Therapy and nursing staff may perform positioning screenings and inventory all ordered safety devices such as cushions, anti-tip/roll-back devices, or non-slip surfaces.

Recognizing the critical safety features of the facility is one of the most important tasks for maintenance during the staff orientation process.  Have you considered rolling out staff education on important facility maintenance criteria into a scavenger hunt that could be enjoyed by the orientees, seasoned staff, and even residents that would like to participate?  This action-oriented training method could turn one of the more uninteresting portions of orientation into a fun event that gets new staff out of the classroom and into the building.  Water shut off valves, fire alarm control/message panels, extinguishers and other important safety equipment locations could be discussed by maintenance and then the scavenger list provided to each orientee who is paired up with a seasoned staff member or resident with a prize awarded to the team locating the most items in the shortest time. Maintenance can circulate through the groups and discuss the specific important features of each safety item.

How are you assisting your Maintenance staff to keep up with evolving guidance and regulations? Investing in training and providing the tools needed to successfully achieve department goals is essential. Does your maintenance department have a copy of the most recent Life Safety Manual policies and forms? Many State Survey Agencies provide this information online. Do they have a preventive maintenance checklist and schedule to follow? Are you keeping the maintenance staff aware of seminars or webinars being offered by your state associations or consulting companies on maintenance “hot topics”?  As with all departments, it is vital that maintenance be provided opportunities for keeping up with the ever-changing information, as well as chances for refresher education.  By encouraging and including Maintenance staff in opportunities to accomplish their work while enjoying fun interaction with the residents, by creating teaching events that can be enjoyable as well as educational, and by providing opportunities for continued learning for the Maintenance staff, you can achieve great care and maintenance of your Maintenance Department.

Make plans to join Proactive for the next “Mission Possible” webinar series on 7/25/23 “Mechanisms of Successful Maintenance Departments”. Following the live event, the recording is available for on-demand training and use by current and future Maintenance staff.


Written By: Brandy Hayes, RN, RAC-CT, RAC-CTA
Clinical Consultant

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