The Department may waive the applicability to a particular unit of one or more of the requirements set forth in 105 CMR 145.000 if:

1. (A) the Department finds that:

   1. (1) compliance would cause undue hardship to the unit;
   2. (2) the unit is in substantial compliance with the spirit of the requirement; and
   3. (3) the unit's non-compliance does not jeopardize the health or safety of its patients and does not limit the unit's capacity to give adequate care; and
2. (B) the unit provides to the Department written documentation supporting its request for a waiver.