Statement of Condition Changes
The August 2016 issue of Perspectives had articles on changes to the Statement of Condition, eliminating long duration plans for improvement to self identified life safety code deficiencies. This was widely reported in everyone’s newsletters and list serves and directly by TJC, but bottom line do you know how your organization dealt with this? The Clarifications and Expectations article in August went into specifics on how to manage through this change and as is customary, TJC came up with several new acronyms you will want to familiarize yourself with including TLW for “time limited waiver,” and SPFI for “survey related plan for improvement,” and SCD for “scheduled completion date.”
The first important change is that life safety code deficiencies identified by TJC on survey will now only have 60 days to correct. If you identify that you will be unable to correct this deficiency within 60 days after survey, then by the 45th day post-survey you will want to request a TLW, or time limited waiver. TJC will forward this request to CMS for their review and approval. The advice from TJC on this issue is very interesting. They advise that if you don’t hear from CMS, then “assume the request is approved.” In addition TJC will allow for an “equivalency,” which is different from a waiver, in that the equivalency states we have an alternative approach that promotes an equivalent degree of safety for the life safety code deficiency. So if you receive a requirement for improvement and you are analyzing corrective actions or equivalent systems you will have a 2-step approach. First step is to apply for the TLW in 45 days, and second step is to apply for the equivalency, which also has to go to CMS for their approval.
The second important changes deals with life safety code deficiencies you discover on your own through routine inspections, i.e., not on survey. These can still be entered as PFI issues; however the content you enter will be “isolated” from surveyor review. It is unclear to us what the perceived value is of this functionality however, since there is no longer any protective nature to this self-identification. The Perspectives article theorizes that it might be a useful management tool at the hospital.
So there are a few action items to consider. If you have open PFI items right now, how quickly can you get them fixed and when is your next survey? Ideally you would like to get them all fixed before that survey or if noticed by TJC you will be cited and only have 60 days to fix it, or you will be requesting a TLW and possibly and equivalency, both of which will involve CMS. For those of you going through survey at the end of 2016 or early in 2017, time to get life safety code deficiencies corrected before survey is limited.
Accreditation Leader Action Item….
At a minimum this article should be shared with your facilities leadership and two questions should be asked:
1. Do we have any open PFI items now and when will they be completed?
2. Do we have any life safety code deficiencies now that might be seen by TJC on their next visit and can we get it corrected before they arrive.
In addition, once you know the answers to these 2 issues a meeting should be scheduled with senior leadership to let them know what the future holds in store for you. They may decide that this is an unacceptable risk and they want to expedite funding or contracting plans to implement the corrective action.
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