Joint Commission Eliminates Plans for Improvement
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The Centers for Medicare & Medicaid Services (CMS) has asked the Joint Commission to make several changes to its Statement of Conditions process, and the Joint Commission will no longer consider hospital Plans for Improvement (PFIs) starting August 1. Instead, all life safety deficiencies will need to be corrected within 60 days, although a time-limited waiver process will be available through CMS regional offices. George Mills, MBA, FASHE, CEM, CHFM, CHSP, director of engineering with the Joint Commission's Department of Engineering, announced the major changes at the ASHE Annual Conference.

Under the new process:

Deficiencies will need to be corrected within 60 days of being identified unless the CMS regional office approves an extension.

All requests for extensions will be handled by CMS regional offices. However, the Joint Commission will allow facilities to submit requests and receive a receipt to show they are in the pipeline waiting for an extension.

The Joint Commission will not review open Plan for Improvement (PFI) items, and PFIs will not be a part of final reports.

The changes will be effective August 1, Mills said. The Joint Commission is an accrediting organization that has deemed authority from CMS and must meet CMS requirements. Mills said the PFI process can still be used as an internal management process.

ASHE will continue to keep members updated about this important change.
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Email subject line:  SOC™ process changes effective Aug. 1: Will affect Life Safety Plans for Improvement

Dear Colleagues—

Please note that effective Aug. 1, 2016, changes will become effective to the Statement of Conditions™ (SOC) process that will affect the survey of Life Safety (LS) chapter requirements. Following August 1, 2016, the following changes to survey will occur:

1. The open Plan for Improvement (PFI) items will no longer be reviewed by the survey team
2. The open PFI will no longer be imported into the Final Report
3. All Life Safety (LS) chapter deficiencies identified during survey will become Requirements for Improvement (RFI) with a 60-day Evidence of Standards Compliance (ESC). For those deficiencies that require more than 60 days, a Time-Limited Waiver process is available.
4. Only equivalency requests related to survey events will be reviewed

The Joint Commission has had the SOC as part of its accreditation program since 1995. The SOC was originally created to allow organizations a process to develop a plan for improvement to correct deficiencies they self-identified within a justifiable time frame based on budgeting and scheduling needs, with Interim Life Safety Measures (ILSM) to ensure patient safety. Initially, these self-identified actions were not documented during survey because the SOC already documented the deficiency. The Joint Commission also created the ILSM process to mitigate risk while resolving the deficiencies. This allowed the SOC process to be the method for organizations to create and submit their Plan for Improvement (PFI), with an amount of time to make the correction that the organization could manage, while still providing a safe environment. Occasionally, an organization would need additional time to complete the corrective action, and The Joint Commission granted extension requests. Many of these extension requests occurred during the six-month automatic extension period.      
CMS has identified required changes to the SOC process, including:  

  • no longer allowing the SOC to document self-identified deficiencies, instead, taking the self-identified deficiencies and converting those to RFIs by the surveyor 
  • no longer allowing more than 60 days for corrective actions unless approved by the CMS regional office
  • the surveyor citing all deficiencies replacing the extension request component with a Time Limited Waiver process, using the Survey-related Plan For Improvement (SPFI) process that will be managed and tracked by the CMS regional office
  • managing the survey-related equivalency process, as defined by CMS, using Salesforce and the SOC to manage and track the CMS regional office action  
  • removing the six-month automatic extension
  • no longer granting requested extensions

Joint Commission leadership, after reviewing the restrictions being placed on the SOC, has determined that the Basic Building Information and PFI components of the SOC no longer fit the quality assessment program it was originally designed as and will become an optional management program and will not be a part of the survey process. Post survey, the CMS Time Limited Waiver and equivalency components of the SOC will be used to manage survey-related deficiencies.  If you have any  questions, please do not hesitate to contact The Joint Commission Department of Engineering at 630-792-5900.



George Mills
Department of Engineering

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