* EC: Revising the Statement of Conditions™ (SOC): PFI rules, SPFI, Time-Limited Waivers, and the end of the 6-month grace period (PDF)[REF: AOM, EC, LDR, SC] EC News, August 2016, Vol 19, #8, Pg 8 JCe1608_B6
Since 1995, healthcare facilities have utilized the Statement of Conditions as a management tool to identify Life Safety deficiencies that could not be immediately corrected. However, recent publications in “The Joint Commission Perspectives” and the “The Joint Commission EC News” August 2016 editions reflect a total revamping of their Statement of Conditions (SOC) process. These changes went into effect on August 1, 2016.
The Joint Commission (TJC) has made changes to the Statement of Conditions largely because the Centers for Medicare & Medicaid Services (CMS) Code of Federal Regulations §488.28 does not allow more than 60 days to complete corrective actions in the physical environment. Consequent changes include the following:
1. Plans for improvement (PFIs) identified by the hospital will no longer be reviewed by the Joint Commission’s survey team or included as a part of the Joint Commission’s final report
2. There will be no extensions offered for PFI’s from TJC (including the automatic 6-month extension)
3. Life Safety deficiencies noted during TJC survey will be identified as “Requirements for Improvement (RFIs)” . These identified RFIs will require a 60-day Evidence of Standards Compliance (ESC) by the Joint Commission. If a Life Safety deficiency identified during survey requires more than 60 days to correct, it will require a “Time-Limited Waiver” (TLW) process.
4. The Joint commission will only review survey related equivalency requests and these will require approval by CMS.
5. The Joint commission has added a new category “Survey-Related Plan for Improvement (SPFI) in order to manage a hospital’s corrective actions when resolving Life Safety deficiencies identified during survey.
6. There is now a new Interim Life Safety Measures (ILSM) for both PFI and the SPFI.
Although a hospital has an option to continue to manage their self-identified Life Safety deficiencies through The Joint Commission’s PFI electronic software, many hospitals have chosen to manage through their own in-house Computerized Maintenance Management software and work order program. The choice to utilize the existing electronic statement of conditions program for both the Basic Building Information (BBI) and the Plan for Improvement (PFI) is now optional.
As of August 1, 2016, life Safety deficiencies identified during an actual survey which will take more than 60 days to repair will become “SPFIs” and be entered into the electronic Statement of Conditions program. There will be an identified tab in the electronic Statement of Conditions for the SPFIs. This tab for SPFIs can provide a list of all SPFIs open and the mandatory limit of 60 days is preset in the program. The hospital organization will be responsible for closing open SPFIs.
When survey identified Life Safety deficiencies will take longer than the 60-day time frame, the facility must go to the “time limited waiver” tab in the eSOC within 45 days from the end of their actual survey and follow the correct TLW request procedures. When a TLW is submitted by the healthcare organization, the facility will be notified that their request will be considered.
For organizations that use The Joint Commission for deemed status, TJC will forward Time Limited Waiver requests to the healthcare organization’s CMS regional office within the appropriate 60-day window. Once the CMS regional office considers the submitted TLW, the Joint Commission will be notified. If the waiver is accepted by the CMS Department of Engineering and CMS regional office, the Joint Commission will update the organization’s scheduled completion date (SCD) and approve the TLW. If the CMS regional office does not grant a requested TLW, the hospital is expected to correct the deficiency within the original 60 day time frame. Should a facility fail to correct an approved Time Limited Waiver deficiency within the approved time frame. it will “result in a decision of Accreditation with Follow-up Survey” .
These recent changes from CMS and the Joint Commission should renew the Healthcare organization’s goal to be “continuously compliant ready”.
Tip 1: Make sure leadership and EOC managers are fully aware of the changes described in this article as their understanding and support will be crucial to effective compliance.
Tip 2: Facilities should take a no-nonsense approach to Life Safety features in order to stay continuously compliant and survey ready. Be proactive by implementing more Life Safety building tours and create work orders ASAP to document corrective measures.
–by Barbara G. Pankoski, CHFM, CHSP-FSM
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One response to “RTN1608_B6_Revising the Statement of Conditions (SOC)”
There is very little good news for state psychiatric hospitals in these recent changes.
State Governors, legislators and Department of Mental Health Directors should be made aware immediately, that building costs are certain to rise dramatically as all CMS surveyed hospitals come into LSC compliance with the 2012 Life Safety Code.
Expenses associated with hiring Engineers to assess all buildings for 2012 LSC compliance must be budgeted into state hospitals operating budgets.
Capital funding will be required to address these deficiencies within the 60 day notice or risk the loss of federal revenue.
If a state hospital has been enjoying a previously granted TJC equivalency for Building deficiencies, this is likely to end.
It also appears that the TJC engineering department will stop its long standing practice of consulting with organizations on LSC equivalencies, deferring to CMS on all deficiency issues.
The one bright light, so to speak, is that state hospital staff will no longer be required to utilize the E-SOC and E-PFI as a self assessment tool. This has always been a difficult process for staff.
These changes have taken away any advantage in “formally” identifying a 2012 LSC problem through internal self assessment.
PI directors and other state hospital staff should begin to learn the “Time Limited Waiver Process” because it will become the primary means of maintaining the TJC accreditation and CMS deemed status, pending the expense of capital dollars for building improvements.