Joint Commission Eliminates Plans for Improvement – Implications to Healthcare Facilities

On July 12, 2016 the American Society for Healthcare Engineering published that The Joint Commission will no longer consider Hospital Plans for Improvement (PFIs). This change was implemented on August 1st.

Breaking down the changes:

  • All deficiencies must be addressed within 60 days of being identified

  • The Joint Commission will no longer review open items and will not issue PFIs lists as a part of their reports

  • Requests for extensions will be handled by the Regional Centers for Medicare & Medicaid Services (CMS)

The following are steps that Healthcare Facilities should take to be proactive to this major change:

In the past, many facilities have used the Joint Commission findings to build ongoing Plans for Improvement to address the deficiencies found. Now that a hard deadline of 60 days is being imposed, this method is no longer practical. Knowing that Joint Commission inspections are thorough, preemptive measures are necessary to ensure compliance:

1.) Assessments:

Assessments are utilized primarily by owners and contractors to:

  • Develop a remediation budget.

  • Determine the extent of an issue.

  • Ensure compliance on a project or facility.

Using a certified and reputable contractor to assess the existing condition of barriers prior to Joint Commission inspections is now more important. The findings of the assessment are then used to develop an internal Plan for Improvement. Identifying and addressing deficiencies before being under the “60-day” clock is crucial.

2.) Staying up to date on the latest “hot items”:

Building Codes, Fire Codes and NFPA are consistently evolving and are formally updated every 3 years. Prepare for compliance by staying up to date on the existing standards and codes including:

  • Doors within rated barriers:

The tolerances of the vertical gap and undercut of the door must be ensured. The doors must have proper identification of being fire rated. Other issues include the door being self-closing and having positive latching.

  • Fire/Smoke Dampers:

Dampers used to maintain rated barriers need to be tested to ensure functionality. The sealing around dampers is also highly scrutinized. A common deficiency found is intumescent firestopping being used to seal around dampers which goes against the U.L. approved manufactures installation requirements of most dampers.

  • Missing/removed fireproofing:

This is a deficiency that has been often identified recently. Fireproofing that is removed to attach clamps for hangers to support mechanical equipment must be replaced. This issue can commonly be found throughout a facility.

  • Firestopping:

Ensure fire rated wall penetrations (mechanical, plumbing, electrical, etc) have been repaired and sealed to keep their rating.

3.) Engaging a specialty contractor to remediate deficiencies ahead of Joint Commission inspections:

Employing a certified contractor to identify deficiencies prior to the Joint Commission prepares your facility to pass inspection. Remediation of deficiencies can be budgeted, and scheduled for the needs of the facility. The documentation provided by a qualified contractor can make the Joint Commission inspections less daunting. By using a containment-contractor that provides both assessments and utilizes in-house employees for field installation and remediation, facilities can be assured of receiving quality and can more closely monitor and control schedule, cost and compliance.

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