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June 2016


This informational release is offered jointly by MSL Healthcare Partners, Inc. and Russell Phillips & Associates, LLC, partners in providing accreditation and compliance services to the United States healthcare industry.

At the 2016 NFPA Conference, Ms. Anne Guglielmo announced additional changes to the standards and survey process.  Anne is an Engineer at The Joint Commission in the Standards Interpretation Group (SIG).  Most of these changes will be effective in hospitals (other than Behavioral Health) on January 1, 2017.  These changes are in addition to the changes previously announced in the June 2016 edition of TJC Environment of Care News.

MSL Healthcare Partners and Russell Phillips & Associates would like to assist you in navigating these changes.  Please review the standards and survey process changes below which were discussed in Anne’s presentation. If you have questions, please feel free to contact us.



As previously announced, the 2017 standard will result in the deletion of:

  1. Tags for A and C Standards
  2. Direct and Indirect Impact
  3. Measures of Success
  4. Risk

However, the tags for documentation required and situational decision rules will remain.  This will make all standards equal in terms of surveyor evaluation; there will be no identified opportunities for improvement, and surveyors will operate under a “see it – cite it” methodology.



The SAFER matrix, as announced in TJC EC News, will score deficiencies as based on the likelihood of harm and the scope of the issue in question.  This method will make distinctions in various aspects of compliance.  For example, EC.02.03.05, maintenance, testing, and inspection of features of fire protection, has both a test performance and a documentation component.  If an organization has not performed a test, that will be evaluated with a higher likelihood of harm than disorganized or incomplete documentation.  Scores in the higher level boxes on the matrix will require answering questions about sustainment of and responsibility for the corrective action submitted as part of the organization’s evidence of standards compliance post-survey.  Any issues scored as “immediate threat to life” (topmost box) will require expedited correction.



Prior to survey, hospitals will need to complete a required documentation checklist and sign an attestation to its accuracy.  An EC/LS pre-survey checklist will also be required.  Given the attestation, documents that were not available at survey will not be accepted for clarification post-survey.  Surveyors will require all documentation to be available during the designated document review session, and likely will not have time to review them if they are not produced until later during the survey.

Insofar as possible, clarifications will be addressed in real time via a phone call with the Standards Interpretation Group (SIG) for any difference of opinion between the organization and the surveyor.  Such a call should be requested by the organization if necessary.  The only clarifications that will be made following the survey is for those findings that the organization believes have been made in error and are NOT document related.



Open PFI items will appear on the organization’s survey report, as they have been.  The Joint Commission remains in discussion with CMS about other potential changes to the PFI.  These changes MAY include:

  1. Removal of the 6-month grace period automatically assigned to projected completion dates.
  2. Removal of extension requests.
  3. Changing “projected completion dates” to “scheduled completion dates”.

Better descriptions of listed deficiencies will likely be required.




Effective July 1, 2016, the sequence of the elements of performance for LS.01.02.01 will be reordered, so that the requirement for an ILSM policy will appear first in the list.

By late summer or early fall, there will be a new PFI section on ILSM assessment, which will require organizations to document in detail their assessment, and which ILSMs are in place for a given deficiency via a dropdown menu.

The final survey report will include a section on ILSM implementation.


About MSL Healthcare Partners, Inc. and Russell Phillips & Associates, LLC

In 2014 Russell Phillips & Associates, LLC (RPA) and MSL Healthcare Consulting, Inc. (MSL) signed a national strategic partnership to provide accreditation and compliance services to their joint client base.  Both organizations bring a high level of special expertise to provide fire, life safety, environment of care, emergency management, code compliance and other safety related services to the healthcare industry.

Please Note:  We will send out an alert when the PFI changes are finalized.