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Briefings on Hospital Safety: The end of the Plan for Improvement

Hospital Safety Insider, October 6, 2016

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In the unlikely event you missed the news, August heralded a big change in the world of life safety compliance, when The Joint Commission declared that as of August 1, Plans for Improvement (PFI) would no longer be accepted by surveyors.

The announcement was made at the 2016 American Society of Healthcare Engineering (ASHE) conference and sent safety and facility officers rushing to check their facilities' extant PFI lists.

In the past, facilities had been able to skirt potentially expensive fines by essentially admitting to a violation they knew would be cited by a surveyor, placing it on a PFI list, and fixing it later.

In lieu of PFIs, any self-reported deficiencies will be listed as a Requirement for Improvement (RFI) by Joint Commission surveyors. Facilities will be given exactly 60 days to correct the violation, though they can petition for time extension waivers at their regional CMS office.

Kevin Kiely, CHSP, CPSO, HEM, a senior healthcare regulatory consultant with Compass Clinical Consulting in Cincinnati, says the PFI decision removes a major disconnect between the Joint Commission and CMS and should enhance the survey process. However, he expects the first 12 to 24 months to be very painful for a lot of facilities due for a survey.

"I think it's going to [improve the process], but it's also going to be an expensive compliance curve for the industry," he says. "Because of the fact that PFIs have allowed organizations to not make repairs, [and instead] be able to adjust them at a later date. What's going to happen now is that it's going to force facilities, finance people, and the executive suite to work collaboratively together on coming up with ways to fix these life safety deficiencies before a Joint Commission survey."

He expects that many facilities will try to obtain a time-extension waiver from CMS' regional offices to get more time correcting deficiencies. That said, he warns that CMS doesn't like granting those waivers and won't give them out without a significant reason.

The elimination of PFIs is one of many changes coming out of The Joint Commission, he points out. As an example, he notes that the new Survey Analysis for Evaluating Risk (SAFER) scoring matrix will go into effect in 2017. Facilities are going to have to pay close attention to these changes, he says, now that they can't use PFIs as a "get out of jail free" card.

Read more here.

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