Last week in Denver, a ballroom full of people listened for nearly 3 hours as George Mills unveiled the new world of Joint Commission compliance.  Up until this presentation, no one outside of The Joint Commission was aware of all of the changes, although there was no shortage of rumors.  I’m sure many of you have heard bits and pieces, rumors, and fears about the changes.

At MSL, we took time to digest them, and plan for moving forward.

Last month we shared changes in the standard markings, scoring process, and clarifications, along with a preview of changes to come to the Plan for Improvement (PFI).  Although those were reviewed in George’s presentation, we will start from that point.

Probably the most significant changes are to the Plan for Improvement, made as a result of CMS requirements, and these will be effective August 1, 2016.  To make a long story short, the PFI, as we know it, will no longer exist.  What we will have available is the same document to use as a management tool for life safety deficiencies in our organization.  Its use will be strictly optional.  It will not be reviewed by surveyors, and there will be no grace period attached.  Open PFI items will no longer be included in the survey report.

All deficiencies identified during survey will be cited as recommendations for improvement (RFIs), whether or not they have been self-identified.  They will be entered onto an SPFI (Survey PFI), and have a CMS-required 60 day completion date.  For those deficiencies that will take longer to correct, there will be a “Time Limited Waiver” (TLW) process.  A TLW must be requested within 45 days post-survey, to allow for review and approval by both The Joint Commission and CMS.  The date on the TLW must be considered a “not to exceed” date, with no further extensions available.  Time limits requested must be “reasonable.”

In addition, the SPFI will feature a drop-down menu to identify the specific ILSMs (Interim Life Safety Measures) associated with the deficiency until corrected.

Under this process, equivalencies will not be proactively granted.  They may, however, be applied for once the deficiency has been cited during survey.  Existing PFI deficiencies for inaccessible dampers must be either resolved with the state fire marshal or have access created.

To accommodate all of this, several changes to LS.01.01.01 are proposed (and are currently being reviewed by CMS):

  • EP 1:  “The organization assigns an individual to assess compliance with the Life Safety Code and manage the Statement of Conditions (SOC) when addressing survey-related deficiencies.”
  • EP 2:  “In time frames defined by the hospital, the hospital performs a building assessment to determine compliance with the Life Safety Chapter.”
  • EP 3:  “When the hospital plans to resolve a deficiency through a survey-related Plan for Improvement (SPFI) the hospital meets the 60-day time frames.”
  • NOTE:  If the corrective action will exceed the 60-day time frame, the organization must request a Time Limited Waiver.

Information previously collected in the BBI (Basic Building Information) section of the Statement of Conditions will subsequently be collected during the survey application process.


Some have suggested abandoning the PFI process completely, opting to wait for the surveyors to identify deficiencies prior to taking corrective action.  At MSL, we believe that compliance with the applicable standards and codes is about providing the safest possible environment for our patients and staff; therefore, we feel proactively managing Life Safety compliance will be even more important in light of this change.

You will note that in LS.01.01.01 EP 2, above, a life safety building assessment is required, in time frames determined by the hospital.  We believe that this step is critical to maintaining a safe environment and that the optional PFI is an excellent tool to manage it.  As you are able to stay ahead of the deficiencies and correct them promptly, you will minimize the impact of these changes on you and your organization.  Where needed for larger projects, the TLW process will allow realistic time frames for corrective action.


We understand this is a lot of information to digest.  Please know, MSL consultants are ready to help you understand the changes and assist you in reaching compliance.  Feel free to contact us if you have questions or if you would like to schedule consultative services.  We look forward to partnering with you!