Facility Management Alert: The Joint Commission Eliminates Plans for Improvement

Facility Management Alert: The Joint Commission Eliminates Plans for Improvement

The Centers for Medicare and Medicaid Services (CMS) may have made life a bit simpler for facility managers. CMS asked The Joint Commission not to consider Plans for Improvement (PFIs) as part of its Statement of Conditions (SOC) process. Instead, they will be an “optional management program” with deficiencies cited only if they are observed by the survey team.

The changes to the PFI process affect the survey of Life Safety chapter requirements and include:

  • Existing Plan for Improvement (PFI) items will no longer be reviewed by the survey team.
  • The open PFI will no longer be imported into the Final Report.
  • 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.
    • 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.
  • Only equivalency requests related to survey events will be reviewed.

ATG believes that this will positively impact the survey preparation process for facility managers by eliminating one area in which healthcare systems are exposed to potential deficiencies.

Because PFIs may still be useful to some hospitals as an internal management tool, ATG will continue to support that functionality as part of our Life Safety Management and Statement of Conditions technologies. ATG's life safety solutions already have the capability to manage these critical 60-day timeframes with automated alerts. They also feature powerful reporting and analytics capabilities, and seamless integration with existing work order systems.

The change went into effective August 1, 2016.

ATG remains committed to providing the tools and technology you need to remain accredited and in compliance with existing CMS and Joint Commission requirements. Please direct questions or comments to 800.804.8442.

You can also request the white paper, "Decoding Recent Joint Commission Changes" by visiting the JLL website at: http://link.jll.com/Decoding-Recent-Joint-Commission-Changes


Compliance, Healthcare Industry News, Life Safety


Contact ATG

To request information regarding ATG or our facility information solutions, please call 800.804.8422 or email atg@atginc.com.

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