(A) The Commissioner may waive the applicability of one or more of the requirements imposed on a particular MIH or Community EMS program by 105 CMR 173.000 if the Commissioner finds that:

1. (1) Compliance would cause undue hardship;
2. (2) The MIH or Community EMS Program's non-compliance would not adversely affect the quality of patient care or patient safety;
3. (3) The MIH or Community EMS Program has instituted compensating features that are acceptable to the Department.