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RTN1407_B8_Changes to PFIs & Equivalencies


*EC: Joint Commission Announces Changes in Addressing Life Safety Code Deficiencies: Modifications to processing PFIs and equivalencies effective July 1, 2014[®]  [REF: EOC, 2014 EC News, July 2014, Vol 17, #7, Pg 8 JCe1407_B8

Two major changes in the SOC went into effect on July 1, 2014.

  1. – The full accreditation decision report on surveys after 7/1/14 will include a report of all open Plans for Improvement (PFI).  The article tells us that TJC considers the open PFI process to be “(essentially) equivalent to the RFI process” in that it requires a documented and measurable correction/improvement within a specified period of time.  From that perspective, one can understand TJC’s desire to effect a more comprehensive survey report by incorporating open PFIs.  Since PFIs track plans for improving Life Safety Code compliance, they also hope this new approach will encourage more discussion of these issues with leadership. A PFI is considered timely if completed within 6 months of the projected completion date. Now, at 4 and 6 months past completion date, the e-SOC will highlight the PFI in Yellow and then Red (overdue).  Red will trigger a ‘coaching call’ from TJC.  Missing two projected completion dates may trigger an on-site survey.
  2. – The final steps of the TJC equivalency (or waiver in CMS terms) process will now require forwarding to and final review/approval by CMS for those hospitals using TJC survey for CMS deemed status.  In addition, traditional equivalencies must be supported by a signed letter from a registered architect, a fire marshall or fire safety professional to be acceptable. TJC does not intend for this to delay its accreditation decisions, but “appropriate ILSM” would need to be maintained during any interim between request and final CMS approval.

The article also includes a brief history of the SOC and a sidebar on page 9 that provides instructions on ‘What to Do if You Have an Overdue PFI’.
Tip: Leadership is encouraged to meet with E&M to identify all open PFIs and establish mechanisms for periodic progress reporting and monitoring until completion. Consider making open PFIs a quarterly agenda item in an appropriate leadership forum.
See also: Related Key Definitions in the Comments section of this article.

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