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Breaking news: PFIs take a flyer!

Well, I suppose there was a certain element of inevitability to this. First, the expulsion of the most global “FIs” in the Joint Commission arsenal—the Requirement for Improvement (RFI) and the Opportunity for Improvement (OFI)—which left only one FI to be expelled, our good friend and (sometimes) benefactor, the Plan for Improvement (PFI). And that day has come (I don’t think there are any intact FIs kicking around, but I could be mistaken…)!

In what will likely end up being filed under the “no good deed goes unpunished” category (I’m more or less characterizing the adoption of the 2012 Life Safety Code® (LSC) as a good deed, though I will submit to you that, if only coincidentally, there has been an unleashing of a most distressing pile of poop), The Joint Commission has announced that, beginning August 1, 2016, it will eliminate the PFI process as a means of managing LSC deficiencies that cannot be immediately corrected and will take longer than 45 days to resolve. Yes, you did not misread that last sentence: say so long, farewell, auf wiedersehen, good bye (can I get an au revoir or adios?!?) to one of the most beloved characters in all of regulatory nuance. So, in place of the PFI process is an expectation for life safety deficiencies to be corrected within 60 days—unless, of course, you want to pursue a time-limited waiver with the friendly folks at your regional CMS office (don’t that sound like a party?). This information comes to us courtesy of the good folks at the American Society for Healthcare Engineering (ASHE), who provided this to members as an advisory released late yesterday afternoon.

When Jay Kumar, my editorial foil at BLR/HCPro asked me for my initial thoughts, there were several expletives that came to mind (and I suspect they are coursing through your collective craniums as well), but I do know that a fundamental means of having some element of control (even if it was somewhat illusory in nature) in managing conditions in the physical environment has pretty much been ripped from our hands. I guess we could look at this as one more piece of the “becoming more like CMS” movement that has been afoot for quite a few years now. Or maybe, as CMS never really accepted the PFI process as an alternative means of LSC compliance, they finally told TJC to cease and desist. I’m thinking this probably also pretty much quashes any thought that the Building Maintenance Program will ever be anything more than it is now (at this point, I’m not really sure what it is beyond a means of organizing the maintenance of certain life safety building features, not a bad thing, but not quite as compelling as it once was).

The process as outlined in the ASHE Advisory goes a little something like this:

 

  • Deficiencies will need to be corrected within 60 days of being identified unless the CMS regional office approves an extension.
  • All requests for extensions will be handled by CMS regional offices. However, The Joint Commission will allow facilities to submit requests and receive a receipt to show they are in the pipeline waiting for an extension.
  • The Joint Commission will not review open PFI items, and PFIs will not be a part of final reports.

Now before you get overly panicky, apparently we will still be able to use the PFI process as an “internal management process,” so everything’s good—right?

I guess we’re going to have to wait and see how this all unfolds in the field, but I have a sneaking suspicion that, of all the changes we’ve encountered this year, I suspect this one is going to result in the greatest amount of disruption, at least in the short term.

But hey, we work in healthcare—we embrace change! We grab change by the throat, throw it on the ground and kick it ’til it stops moving. We love change!

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.

Wait ’til your father gets home…

Well, it would seem that there are any number of folks out there in the safety world who are not familiar with the expectations relating to the timely completion of PFIs and now The Joint Commission has decided that they need to use a bigger stick (bigger than a finding of Conditional Accreditation) to garner the attentions of the miscreants who have PFIs that are more than six months past their projected completion date and have not requested an extension.

So according to information on The Joint Commission website on May 30, notifications addressed to the organization’s primary accreditation contact and the facilities director have gone out to all organizations with overdue PFIs. And not to put too fine a point on things, if the overdue PFIs have not been resolved or an extension requested, a second notification to those same folks will go out on June 12, with the addition of each organization’s CEO.

If I’m doing my math correctly, those of you who were in the penalty box as of May 30 have just about a week to either resolve the deficiency or request an extension—or have a little face time with your CEO (I’m thinking that third curtain is probably the one you’d want to avoid). A third notification is scheduled to go out on June 23, if the first two messages weren’t sufficiently impactful. And if that still isn’t enough, there’ll be an opportunity for some phone time with one of the engineers from the Standards Interpretation Group (SIG), with which further recalcitrance will be rewarded with an on-site visit. I’m getting goose bumps just thinking about it.

Now, I know that sometimes things can get a little hectic as we do battle against the forces of evil, but this is one priority that’s going to have stay way up on the list (BTW: Going forward, any PFIs that go more than six months past the projected completion date will generate an automatic notification to the engineering folks in Chicago). And thus, I encourage you to do a couple of things:

  • If you have an open PFI that has gone more than six months past the projected completion date (and that means you got a notification), either resolve the issue or request an extension
  • Be very judicious in identifying projected completion dates for future PFIs. Make sure you give yourself enough time to resolve the deficiency; if you have to build in some time for the vagaries of the budgeting process, then please do so (and don’t forget to assess for ILSM implementation—a most important thing to remember). It is possible that you might be “challenged” during a survey relative to the completion timeframe, so you need to be thoughtful (for example, giving yourself 10 years to replace a door is probably a scenario that will raise some eyebrows) about how you allocated time. But as long as you are “honest” in your ILSM assessment, you will be able to demonstrate that you are appropriately managing the risks associated with the deficiency—for as long as it takes to resolve the deficiency.

What is a Life Safety Code® deficiency?

One of the time-honored pursuits, mostly as a function of what you can and cannot manage through the plan for improvement (PFI) process, is what exactly constitutes a Life Safety Code® (LSC) deficiency. Just so you know, I used the “exactly” descriptor for a reason—because the definition, while pretty clear (at least to my mind—feel free to disagree) is a fair distance from exact, but read on and maybe it will become a little more clear.

The “secret” to all of this can be found on pp. 24-25 of the 2000 edition of the LSC. Contained on these two pages are the “documents or portions thereof” that “are referenced within this (Life Safety) Code as mandatory requirements and shall be considered part of the requirements of this (Life Safety) Code.” Thus, these requirements include some of the items you’d probably expect to be there: NFPA 10 Standard for Portable Fire Extinguishers, NFPA 13 Standard for the Installation of Sprinkler Systems, NFPA 70 National Electrical Code, NFPA 99 Standard for Health Care Facilities; and maybe some that you wouldn’t necessarily include in the mix, but make sense when you think about it: NFPA 30 Flammable and Combustible Liquids Code, NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Operations. Not that I usually get into product endorsements, but I think even a casual glance at the list of required elements would point you towards having a subscription to all the NFPA codes—and that’s not getting into the other publications cited as required (ANSI, ASME, UL) because they all have a share in the mandated references. Oh yes, and the final “other” publication mentioned is Webster’s Third New International Dictionary of the English Language, Unabridged; you could probably get into a lot of trouble with that…

Therefore, an LSC deficiency is really any condition or practice that is not compliant with any of the referenced codes (is your head spinning yet?), so you can probably craft a PFI for just about any safety-related hazard. In this world of ever-shrinking operational budgets, the PFI process may become an everyday tool as opposed to the once in a blue moon process it has sometimes been in the past. Remember, if the deficiency can be resolved within 45 days, then you can use your work order system. But if you can’t resolve the deficiency within 45 days (and budget constraints are no doubt going to have a greater impact on that in the future), then the PFI could become your new BFF.