There seems to be much discussion lately on how to manage the Joint Commission Statement of Conditions Plans For Improvement (PFI) on inaccessible dampers. Joint Commission has instructed healthcare organizations to write a PFI for inaccessible fire or smoke dampers, and place a projected completion date of 6 years on them.
I have been telling my clients to close the PFI out at the end of the 6-year cycle; examine the fire dampers again to see if anything has changed that now allows them to be accessible (and then test them); and if they are still inaccessible, write up a new PFI with a new 6-year projected completion date. I vaguely remember that Joint Commission initially wanted hospital to request another 6-year extension on PFIs for inaccessible fire dampers, but I think they soon realized their error as they would be over-whelmed with extension requests. Also, they typically only allow one extension per PFI, so after the first 12 years, would they grant another extension? I also remember them saying to just close out the PFI and write a new one.
I don’t have a copy of the 2007 EOC article on the PFIs for inaccessible fire dampers, but 7-year old information seems a bit old for me to trust. People and organizations change their mind in 7-years. If anyone has any doubt, they should contact the Standards Interpretation Group at Joint Commission directly and ask them. Their number is (630) 792-5900, select option 6.