Joint Commission PFI List

images4ZUW90XGI received an email from a client who was confused about the changes to the Joint Commission Plan for Improvement (PFI) list found in the Statement of Conditions (SOC). He initially thought the recent CMS imposed changes on the PFI list meant that he should no longer use the PFI list for his life safety deficiencies. Then, he received advice from another consultant that he must list the life safety deficiencies on the PFI list and must do so with 45 days of discovering the deficiencies. He contacted me saying he thought he was in trouble because he was more than 45 past due and asked me for advice.

I responded saying I thought he was receiving some confusing advice, and I did not believe he was in trouble. Here is my take of the Joint Commission PFI program:

  • CMS no longer allows Joint Commission to not cite an organization on the survey deficiency report for a life safety deficiency just because it is listed in the PFI section of the Statement of Conditions.
  • Therefore, Joint Commission will cite all items listed on the SOC PFI list on the survey deficiency report, but will do so on a special section of the report at the end called the Plan for Improvement – Summary, and it looks like this:

Plan for Improvement – Summary

The Plan for Improvement (PFI) items were extracted from your Statement of Conditions™ (SOC) and represent all open and accepted PFIs during this survey. The number of open and accepted PFIs does not impact your accreditation status, and is fully in sync with the self-assessment process of the SOC. The implementation of Interim Life Safety Measures (ILSM) must have been assessed for each PFI. The Projected Completion Date within each PFI replaces the need for an individual ESC (Evidence of Standards Compliance) so the corrective action must be achieved within six months of the Projected Completion Date. Future surveys will review the completed history of these PFIs.

  • No evidence of standards compliance (ESC) is required on findings in the Plan for Improvement – Summary section, such as there would be for ‘normal’ deficiencies cited during the survey on the Requirements for Improvement section.
  • There is no Joint Commission standard that actually requires you to list your life safety deficiencies on the PFI list within 45 days of discovery. Joint Commission wants you to do so, but there is no standard that actually requires you to do it. If you choose to not list your life safety deficiencies on the PFI list, there is no repercussion. The sole purpose of the PFI list now (after the CMS imposed changes), is to provide you with a vehicle to manage your life safety deficiencies. I see the PFI list as a choice: You can manage your life safety deficiencies through the use of the PFI list, or you can manage your life safety deficiencies through the use of your computerized maintenance management system (work orders).
  • If you choose to not list your life safety deficiencies on the SOC PFI list, then you manage the deficiency through your work order system. If the surveyor observes the life safety deficiency during a survey (and the deficiency is not on the PFI list), then he/she will cite it under the ‘normal’ Requirements for Improvement section of the survey deficiency report, and you will need to submit evidence of standards compliance (ESC) within the designated 45 or 60 day timeframe. An acceptable ESC response is to either resolve the life safety deficiency, or to state you will list it on the PFI list with a projected date of completion. But this is all dependent on the surveyor observing the life safety deficiency and citing it on the survey deficiency report.
  • If you choose to list your life safety deficiency on the PFI list, then all the surveyor will do is take the items listed on the PFI list and enter them automatically into the survey deficiency report under the Plan for Improvement section, which does not require an ESC submitted within 45 or 60 days.
  • If you miss the 45 day window to enter a life safety deficiency in the PFI list of the SOC,  that is not a problem. Since there is no Joint Commission standard that says you have to list life safety deficiencies in the PFI list, then there is no standard that says you have to do it within 45 days of discovery. The 45 day rule is just a guideline… a suggestion, if you will. Joint Commission may want you to think it is a rule, but it is not. There are no repercussions if you listed the life safety deficiency on the 50th day, or the 75th day instead.

It’s your decision, but I would advise hospitals to continue to list their life safety deficiencies on the SOC PFI list; but you do not have to. There is no Joint Commission standard that says you have to do so. But there is a slight advantage to list the life safety deficiencies on the SOC PFI list: It will be entered under the Plan for Improvement section of the survey deficiency report which does not require a 45 or 60 day response, as opposed to listing the life safety deficiency under the Requirements for Improvement section which does require a ESC response within 45 or 60 days.

Having it listed under the Plan for Improvement section of the deficiency report will also provide awareness to the CEO/COO suite of the life safety deficiencies that they may not have been aware of otherwise. That may be a good thing… or perhaps it may not.

DON’T FORGET: You will need to assess the life safety deficiency for Interim Life Safety Measures (ILSM) regardless whether or not the deficiency is listed on the SOC PFI list.

I mention all of this because some facility managers may overlook placing a life safety deficiency on their SOC PFI list within the 45 day window of discovery, and feel they are in trouble.

Congratulations! CMS Approves The Joint Commission for Six More years

I suspect most of you didn’t give this much thought, but ever since 2009, The Joint Commission has had to apply to CMS for their deeming authority to survey hospitals and other healthcare organizations on behalf of the federal agency for Medicare & Medicaid reimbursements. Joint Commission was approved by CMS in 2010 for 4 years, which would expire this year if they did not re-apply.

Re-apply they did and this time it appears CMS was waiting for them and gave them a huge list of things they needed to change about their standards and practices, or they would not receive CMS deeming approval. In all, CMS identified at least 52 specific items that Joint Commission needed to address before they would receive the deeming status that they needed to stay in business.

To their credit, The Joint Commission did the work necessary to comply with the CMS demands. The changes they made that would be most notably in the physical environment areas, include:

  • Open PFIs will be cited on the final survey report;
  • Agreeing that only CMS can approve equivalencies;
  • Issuing two new Elements of Performance (EPs) which address the requirements for the organization to conduct risk assessments when determining the best equipment maintenance strategy, under EC.02.04.03, EP 24, and EC.02.05.05, EP 6;
  • Issued new EC.02.02.01, EP 18 requiring radiation workers to be checked periodically;
  • Issued new EC.02.02.01, EP 19 requiring procedures for trash storage and disposal;
  • Changed EC.02.03.01, EP 10 to include the phrase “and report fire alarms”;
  • Changed EC.02.05.03 to add the rooms “intensive care, and emergency rooms”.

You might be surprised to learn how hard The Joint Commission has been working to re-write their standards to comply with CMS’s demands. It is easy to think of the largest accreditor as an agency that perpetuates itself year after year, but that is not the case anymore. They have a boss (CMS) that they have to report to, and follow their directives. One indication of the seriousness of this issue, is usually The Joint Commission announces changes to the standards six months before they become effective. The fact that most of the changes mentioned above are effective July 1 (or July 2), 2014, and were only announced to the public during June, says they deviated from their normal practice to satisfy CMS.

It must have worked, since CMS published a statement in the Federal Register on Friday, June 27, 2014 announcing their approval for The Joint Commission as a deeming authority, for another six years. I seriously mean this when I say Congratulations! to The Joint Commission for this achievement. I know it must have been difficult.

Changes With Equivalency Requests for The Joint Commission

imagesO752ZQ8RAs a result of the June 4, 2014 online announcement by The Joint Commission which identified major changes for the Statement of Condition Plan for Improvement (PFI) list, they also mentioned that beginning July 1, 2014 all equivalency requests submitted to them will be passed along to the appropriate CMS Regional Office for their approval.

What The Joint Commission did not say is CMS will not accept any equivalency requests unless it is submitted as part of the organization’s Plan of Correction. This means, hospitals will no longer be able to submit an equivalency request prior to a survey, but will only be able to submit equivalency requests after the Life Safety Code deficiency is cited in a survey report.

What affect will this have on hospital facility managers? I think both changes involving the PFI list and the equivalency requests has the potential for a huge impact on the overall safety of the physical environment, and it won’t be positive.

In just the two days since Joint Commission announced this change, I must have talked with or emailed with over 20 different facility managers and safety officers of Joint Commission accredited hospitals, discussing what options they have with these new changes. This has many of these individuals very concerned since two key tools are changing on how they manage their Life Safety Code deficiencies.

Allow me to summarize these changes:

1). Beginning July 1, 2014, Joint Commission says all items identified on the PFI list will be cited as deficiencies on the survey decision report. No longer will hospitals enjoy a pass from receiving a written deficiency in the survey report for anything identified on the PFI list. [I talked with one facility manager who has over 200 items on his PFI list and their organization is in the survey window for their triennial survey. He needs to clear those PFIs or risk having them identified on the survey report.]

2). Joint Commission says they will review equivalency requests and send them on to the CMS Regional Office for final action. Since CMS does not accept equivalency requests for LSC deficiencies that have not been cited on a survey report, no longer will facility managers be allowed to be proactive and seek an equivalency for a deficiency prior to a survey.

So, I see a very strong potential for facility managers to discontinue being proactive and identify their LSC deficiencies prior to a triennial survey, since there is no relief from the PFI list and there is no opportunity to seek an equivalency. They very likely will take the stand of wait-and-see if the surveyor finds the deficiency and then deal with it afterwards. I fear our industry may fall back into the “hide our skeletons” concept of over 20 years ago. No longer will some facility managers want to be transparent and self-identify their problems. By failing to self-identify their deficiencies, those deficiencies do not get resolved, and if the surveyors fail to identify them, then they likely will not get resolved at all. How safe is that for our patients?

Do not misunderstand me… I do not advocate facility managers to discontinue being proactive and identifying their LSC deficiencies prior to a survey. In fact, I encourage them to continue as though nothing has happened in regards to the PFI list, and still use it as a tool to manage their deficiencies. But, human nature being what it is, I suspect many hospitals will not be as safe as they once were because some facility managers will no longer be proactive and self-identify their LSC deficiencies.

And, you can forget about the cost effective and economical Traditional Equivalencies that Joint Commission used to accept. CMS will not accept those at all, and will only accept the more costly Fire Safety Evaluation System (FSES) as identified in NFPA 101A.

I think this is a very sad day for healthcare. While I was an advocate for fair play amongst all the accreditation organizations, I wanted CMS to approve the advantage that Joint Commission had with the PFI list and approving equivalencies prior to the deficiency being cited, for all accreditors, not just for Joint Commission. Instead, CMS did not clearly understand the potential actions their insistence will cause.

It looks like CMS will not stop until all the accreditation organizations are homogenized into one big quasi-government group whereby you won’t be able to tell them apart. What good is that?

Follow Up on Changes to the PFI LIst

imagesFWHXWLWMSince yesterday, I have received a lot of emails and calls concerning the Joint Commission announcement on changes to their PFI list. On Wednesday, June 4, 2014, Joint Commission published an online article which announced major changes to their survey decision report process, which will become effective July 1, 2014.

Currently, an organization is encouraged to report any Life Safety Code deficiency that they cannot resolve within 45 days of discovery, onto the Statement of Conditions Plan for Improvement (PFI) list, and identify a projected completion date. For many years (20 years?) placing a LSC deficiency on the PFI list provided the organization relief from a surveyor finding in the event of a survey. In the accreditation organization’s announcement on Wednesday, items listed on the PFI list will no longer be free from a surveyor’s citation beginning July 1, 2014.

The reason is the Centers for Medicare & Medicaid Services (CMS) has insisted that the Joint Commission stop this practice, and cite every deficiency that the surveyor sees during the survey. To their credit, Joint Commission has agreed to comply with the federal agency’s directive.

But I have received many emails and telephone calls from facility managers asking “What should I do?” Now that the Joint Commission will cite any item identified on the PFI list, many facility managers are reluctant to self-identify their deficiencies that will likely lead to a surveyor finding.

Let’s remember what the Statement of Conditions PFI list is all about: It is a Joint Commission management tool designed for facility managers to self-report Life Safety Code deficiencies so they can manage the resolution of the deficiency.  The PFI list is there for you to use in order to track the LSC deficiencies to completion. It is not a device in which Joint Commission can say “Gotcha” and hit you over the head.

There is no Joint Commission standard that says you must enter all LSC deficiencies into the PFI list that cannot be resolved within 45 days. Joint Commission does have a Frequently Asked Question (FAQ) on the subject, and the answer they provided is as follows:

The Joint Commission allows resolution of a deficiency by either correcting it immediately (preferred), managing it using a corrective maintenance work order system (with tracking capabilities) with resolution within 45 days, or creating a Plan for Improvement (PFI) and managing it using the electronic Statement of Conditions (SOC).

This is not a standard requirement of the accreditation organization, but more like a recommendation. I see it as an option for the facility manager. He/she does not need to enter the LSC deficiencies in the PFI list if he/she does not want to, especially now that there is no incentive to do so.

But don’t let that short-sightedness be your downfall: It may be better to list all your LSC deficiencies that you cannot resolve within 45 days on the PFI list and risk being cited for them, in order to track and manage each deficiency to a successful conclusion. I guess each facility manager needs to consider all of the alternatives and make their own decision.

For those that missed the Joint Commission announcement, click on the following link:

Joint Commission Announces Changes to PFIs and Equivalencies

Yesterday, Joint Commission published an online notice of changes to their survey decision reports effective July 1, 2014, that effectively eliminates the strategic advantage of healthcare organizations self-reporting Life Safety Code deficiencies on the PFI list, and changes how equivalencies are approved. The reason for these changes is to align Joint Commission’s survey process with the requirements of the Centers for Medicare & Medicaid Services (CMS). Joint Commission is in the process of having their renewal application for deemed status from CMS approved, and this action appears to be a direct result of CMS insistence to follow their rules.

CMS has for many years prevented other accreditation organizations (HFAP and DNV) the ability to have documents similar to the PFI list that provides protection from surveyor findings during a survey, and eliminated those AO’s authority to approve equivalencies. It appears now that by this action, a level playing field with all the AOs has been achieved and any unfair advantage that Joint Commission had is eliminated.

Specifically, the changes that Joint Commission announced in their online publication stated:

  • While Joint Commission retains their Plan For Improvement (PFI) section of the Statement of Conditions, they eliminated the protection of a finding on a survey report. They now say they will list all open, unresolved PFIs on the survey decision report, which puts them on the same level with the other AOs.


  • Joint Commission will no longer approve equivalencies, but will submit them to the appropriate CMS Regional Office for their approval. This also puts Joint Commission on the same level as the other AOs. In addition, this appears to eliminate the Traditional Equivalencies that Joint Commission used to approve, as CMS will only accept equivalencies that are based on NFPA 101A, which uses the Fire Safety Evaluation System (FSES).

Joint Commission also announced that they have created a new section in the survey decision report called the “Opportunities For Improvement” (OFI), in addition to the still current “Requirement for Improvement” (RFI) section.  This is significant as currently single observations of Category C elements of perforamce are not posted on the survey decision report, which is contrary to CMS’s directive. CMS has stated for years that all deficiencies observed by a surveyor must be cited in the survey decision report.

Now, single observations of Category C elements of performance will be cited in the survey decision report under the OFI section, rather than the RFI section. The ability to clarify away surveyor findings after the survey on Category C standards in the OFI section is eliminated. However, the online notice did not say that Joint Commission is eliminating the ability for healthcare organizations to clarify Category C findings scored under the RFI section.

So, based on this online notice, it is apparent that CMS held their ground with Joint Commission and made them implement the changes to eliminate the uneven playing field. It appears that all AOs are on the same page, and Joint Commission no longer has an unfair advantage on PFIs or Equivalencies.

It appears that these changes only applies to Joint Commission programs that are under the authority of CMS.

To review the online notice on these significant changes, go to:

Clarification from The Joint Commission

Did you notice the January 29, 2012 issue of the Joint Commission Online? Among other articles, they had an article called “Clarification of storage requirements for freestanding medical gas cylinders.” In this article, they said improper storage of medical gas cylinders poses a number of hazards to patients and staff, which is true.

In fact, I don’t disagree with anything stated in the article. It’s all good stuff. But if you read the online article, you might be a bit confused. First, the article states that their standards EC.02.06.01, EP 1, and EC.02.03.01, EP 1 both require compliance with the NFPA requirements (presumably they mean on gas cylinder storage). A review of these two standards do not mention anything about NFPA standards or requirements. They do mention (generally speaking) that interior spaces need to be safe and suitable, and the hospital minimizes the potential for harm. Now, failure to properly store medical gas cylinders can easily be scored under either of these two standards, but to the point of the online article, there is nothing in these two standards that requires compliance with any NFPA requirement.

The January 29, 2014 online article does say that NFPA 99 (1999) section 4- mandates requirements for storing nonflammable gas cylinders, which it does. But NFPA 99 (1999) 4- says if stored in the same enclosure, empty cylinders shall be segregated from full cylinders, and empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

However, in the online article, it says the Joint Commission requires organizations to segregate full, partial and empty cylinders by physically separating and clearly labeling the cylinders. Does this mean healthcare organization are required to have three means of separation: one for full cylinders; a second for partial cylinders; and a third for empty cylinders? Not sure…

The online article continues to say that once a cylinder valve is opened, it is considered empty, even if gas remains in the cylinder. The article did not say once the valve is opened the cylinder is considered partial. Therefore, one could deduct that you only need to have two separations: one for full cylinders; and a second for partials and empties.

But the article also says an organization can have a full rack, a partial rack, and an empty rack, as long as unopened cylinders are segregated from all opened ones. What does this mean?  Is Joint Commission requiring three racks: one for full; a second for partials; and a third for empties? I don’t think so, because the sentence starts with the words “An organization can…” The word ‘can’ does not imply a requirement. Also, the sentence just before that says “For storage purposes, any opened cylinders must be physically separated from full (unopened) cylinders.” That sentence did not mention anything about a separate rack for partials.

At best, this clarification from the largest accreditor of healthcare organizations is confusing. You might be thinking why didn’t I just contact Joint Commission directly and get this resolved? I wish I could. I have been shut-out of the information loop from the official Media Relations department, and they will not return my emails, or respond to my requests for information.

My advice on this issue: Make sure you segregate your full medical gas cylinders from other cylinders that are considered partial or empty. Provide two means of segregation wherever you store medical gas cylinders, and make sure they are separated by using different racks, physical barriers or color-coding the storage racks. I suggest you segregate your cylinders into two different storage areas (instead of three) because that is what NFPA 99 suggests.

Incidentally, the requirement for healthcare organizations to comply with NFPA 99 (1999 edition) comes from sections 18/ of the 2000 Life Safety Code, and compliance with the LSC is required under Joint Commission standard LS.01.01.01. It is also covered under LS.02.01.30, EP 25.

PFIs on Inaccessible Fire Dampers


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.


Using Certain Sections of the 2012 Edition of the Life Safety Code

What process should be used to take advantage of the recent CMS correspondence that deals with allowing mobile equipment, such as patient lifts and gurneys in the corridors? To refresh your memory, CMS S&C Letter 12-21 issued March 9, 2012 allows hospitals and nursing homes the opportunity to start using certain sections of the 2012 edition of the Life Safety Code, by considering requests for waivers to the current 2000 edition of the Life Safety Code, without the organization having to show an “unreasonable hardship”.

The sections that CMS will allow, are (references are to the 2012 edition of the LSC):

  • 18/ which allows projections into the means of egress corridor width for wheeled equipment and fixed furniture
  • 18/ though 18/ which allows certain types of alternative kitchen cooking arrangements
  • 18/, (3), and (4) which allows the installation of direct vent gas fireplaces in smoke compartments containing patient sleeping rooms and the installation of solid fuel burning fireplaces in areas other than patient sleeping areas
  • 18/ which allows the installation of combustible decorations on walls, doors, and ceilings.

If you are Joint Commission (TJC) accredited, the process to follow, is to request a Traditional Equivalency from TJC to allow you to begin using the 2012 edition of the LSC on those 4 or 5 issues identified in the CMS S&C Letter 12-21. TJC requires that you have a written opinion from one of the following three individuals, who states that you meet the expectations in the 2012 edition of the LSC:

  • Local AHJ on fire safety
  • Registered architect
  • Fire safety engineer

You then write a cover letter requesting a Traditional Equivalency and submit it along with the written opinion from one of the above individuals. TJC should approve your Traditional Equivalency request, and then you may begin using the new 2012 references. The important thing to understand in this issue, is you do not request a waiver from CMS to use the 2012 edition until such time you are cited by a state agency representing the CMS. Then, as part of your Plan of Correction, you submit a waiver request through the state agency to the CMS Regional Office who will review and probably approve your request. For many of the organizations out there, you may never get cited by a state agency representing CMS before the new 2012 edition of the LSC is adopted, which is hopefully within the next 24 months.