Q: Hello Brad, I hear the SOC as of 8/4/2016 will no longer be used. If time is needed to do a repair for a life safety item we need to apply for a waiver from CMS and if granted, will be for 60 days. how true is this rumor? Please say it ain’t so!
A: Well… it ain’t so as you describe it, but here is the truth:
CMS has told Joint Commission that they can no longer allow hospitals more than 60 days from the end of the survey to resolve a LSC deficiency, unless the hospital has applied for a time-limited waiver, which acts as an extension. This effectively eliminates any positive action the Plan For Improvement (PFI) section of the Statement of Conditions. However, contrary to what you’ve heard, the SOC remains in the format of the Basic Building Information (BBI) section. Joint Commission has said their surveyors will no longer look at the PFI section, and Joint Commission will eliminate the special section at the end of the survey deficiency report that contained the PFIs. Now, all LSC deficiencies will cited in the main portion of the survey deficiency report and will not receive any special dispensation, such as the PFIs used to.
Back in 2014, CMS told Joint Commission that they can no longer not cite a LSC deficiency even if it was listed in the PFI section. So, since July 2014 all LSC deficiencies listed in the hospital’s PFI section were cited in the end of the survey deficiency report and did not require a Plan of Correction (PoC) since it already had one in the PFI list. Fast forward two years, and CMS told Joint Commission again that they did not like the fact there was no PoC for the LSC deficiencies listed in the PFI section, and they did not like the hospital taking more than 60 days to resolve the LSC deficiency without CMS permission.
So… beginning August 1, 2016, the PFI list is effectively defunct, and all LSC deficiencies cited during a survey will need to be resolved within 60 days of the end of the survey. If it cannot be resolved within 60 days of the end of the survey then the hospital must submit a time-limited waiver request to Joint Commission who will then forward it to the proper CMS regional office for their review and approval. Once approved, the time-limited waiver request is good until the next survey cycle where it will become invalid and if the deficiency remains it will be cited again.
Hospitals may still submit regular waiver and FSES equivalencies for LSC deficiencies that are an unreasonable hardship to resolve. That is an entirely different process and they are submitted to the accreditation organization and then it is forwarded to CMS regional office for review and approval.
Joint Commission says the PFI list will still be part of the SOC and hospitals may use it as a tool to manage their LSC deficiencies. But I advise my clients to no longer write PFIs in the SOC and manage their LSC deficiencies with the Computerized Maintenance Management System (work order system). That way, there is no chance of a unscrupulous surveyor looking at the PFI list and then writing those deficiencies into the survey deficiency report.
It’s a whole new world out there and CMS is bound and determined to have everything their way.
Brad Keyes, CHSP