Q&A: Entering deficiencies in the PFI for Life Safety compliance

Q: Our assessment for compliance with the LSC has been made, and some deficiencies have been identified. The problem is that some of these deficiencies will take longer than 45 days to resolve. What should be my plan of action?

A: If the deficiency cannot be resolved within 45 days of discovery, you can enter the deficiency in the Plan for Improvement (PFI) portion of the Statement of Conditions (SOC).

When entering information in the PFI portion, it is extremely important to have realistic projected start dates and projected completion dates. These dates can be adjusted by the organization until The Joint Commission has formally accepted them, which only done during an onsite survey. Once the SOC has been accepted by a Joint Commission surveyor during a triennial survey, your organization cannot change these dates except through special written permission from The Joint Commission. Although you are automatically granted a six-month extension without having to ask for it, if your organization has exceeded the projected completion date by more than six months without an extension granted by The Joint Commission, you may very well be scored AFS-13 and accreditation with follow-up survey will be issued, which could lead to a Contingent Accreditation decision. Therefore, it is critically important to monitor projected completion dates on all PFIs to ensure your organization is not past due.

Ask to see the SOC for your organization and look for projected completion dates of all the PFIs to validate they are completed or will be completed on time.

Editor’s Note: Do you have a question about clarifying RFIs, policy management, or survey-prep for our experts? E-mail your queries to Jaclyn Beck at jbeck@hcpro.com and receive one-on-one advice from our experienced advisory board. Submit a question and our credible sources will provide you with a timely answer.