The Commissioner or the Commissioner's designee may waive any requirement imposed by 105 CMR 722.000 when:

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