Greeley Reflections

Accreditation Connection, November 23, 2009

Part 2 of 5

Gray matters: Red alert


Question #1: So, the first question to ask of your facilities folks is “are we managing any LSC deficiencies as PFIs?” If the answer is no, proceed to Question #3?. But if the response is “yes” or some variation which may or may not include some hemming and hawing (they are, after all, trying to figure out why you’re asking), then proceed directly to Question #2.

Question #2: “Have we completed an Interim Life Safety Measures assessment for the deficiencies being managed as PFIs?” Just to give you a sense of where we are with this, the PFI process is designed to be used when there are LSC deficiencies that cannot be resolved in a relatively short period of time (the agreed upon time frame seems to be anything longer than the 45-day range – see the FAQ for more info on this.

Thus, anything that is being managed as a PFI must be considered a LSC deficiency; if the response is that a PFI or PFIs are not LSC deficiencies, then you will politely, but firmly, inquire as to why they are on the PFI list if they are not LSC deficiencies–there’s a world of potential hurt if this process is not solid. If the response to Question #2 is yes, just ask to see it; if it’s not documented in a “shareable” fashion, encourage everyone to put pen to paper, fingers to keyboard – whatever it takes to document the assessment.

They will tell you that it’s not required to be documented, and strictly speaking it is not an in-your-face requirement, but I will tell you with absolute certainty that the same rules apply here as they do with clinical documentation – if you didn’t document it, you didn’t do it. If the response to Question #2 is in the negative, proceed to Question #3, which we will discuss in the next issue.

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