I 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.