June 01, 2015 | | Comments 1
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And then came the last days of May…

This year has brought a lot of CMS work this year, both in preparation for impending visits and in response to endured visits. There’s just nothing particularly pleasant about the process, but I guess there’s naught that can be done for it.

One of the interesting, and extra not-pleasant developments in this realm is the use of the Plan for Improvement (PFI) process during CMS surveys to bludgeon facilities professionals into pretty much abandoning any pretense of being able to plan/prioritize the resolution of existing Life Safety Code® (LSC) deficiencies. As I think we’ve discussed, one of the changes in the Joint Commission final report is that (if your surveyor remembers to accept them) it includes a listing of all your PFIs, which gives the CMS LSC surveyors a ready-made starting point for their report (CMS has really never bought in to the whole PFI process for managing LSC deficiencies, which is very unfortunate). Recently, I worked with a client who had to complete all their damper repairs that were being managed through the PFI process and I started thinking about a number of folks who are managing their inaccessible dampers, etc., through the PFI process and then I start thinking, “Wouldn’t that suck a ton of eggs if the PFI report becomes a roadmap for CMS to have their way with folks?”

I guess this is all part of having to deal with the various authorities having jurisdiction (AHJ) and while I suppose not every AHJ is going to be prickly about this stuff, I am reasonably certain that there are those would who be more than happy to give folks a good regulatory thumping. We are in a time of great uncertainty and chaos as we are held to standards that are increasingly best noted as antiquities. But until we can get can somehow suborn a more rapid cycle of code/standard adoption, I guess we’re just going to have to spend far too much time and energy on things other than taking care of our patients.

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Filed Under: CMSLife Safety CodeThe Joint Commission

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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  1. Another solid post, Mac. Thanks! Your point about how different State Fire Marshals, as the agent of CMS on these issues, is well taken. There are many good stories of differences between states, in terms of approach, style, and experience. As usual, investing in, and maintaining, good relationships is a great way to do business… for all.

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