Insights Category: Technical Information

The Joint Commission has recently announced a new approach for identifying and evaluating risk levels associated with deficiencies cited during surveys. This new approach, referred to as Survey Analysis for Evaluating Risk (SAFER) matrix, is intended to provide organizations with additional information related to the risk of deficiencies to assist them in prioritizing corrective actions. The SAFER Matrix became effective for psychiatric deemed hospitals on June 6, 2016 and will become effective for the remainder of accredited facilities on January 1, 2017. The matrix will illustrate areas of noncompliance at an aggregate level to show the extent (limited, pattern, widespread) and likelihood to harm (low, moderate, high) that cited deficiencies may cause in the event of a fire. At the end of the survey, the facility will be provided with a SAFER matrix within their Accreditation of Survey Findings Report as shown in the figure at left.

The SAFER Matrix replaces the current scoring methodology. Predetermined Elements of Performance (EPs) such as Categories A and C as well as Direct and Indirect impacts will no longer be utilized. Opportunities for Improvement, such as a single Category C finding, will no longer exist. Further, Measures of Success (MOS), which was previously used as an audit to determine if a certain action is effective and sustained, will not be required for certain Category C findings. Instead, surveyors will perform an on-site evaluation of identified deficiencies to place each EP within the appropriate cell according to the extent and likelihood to harm. Deficiencies of higher risk will still require an Evidence of Standards Compliance (ESC) to be developed and submitted by the facility related to corrective actions. Further, Immediate Threats to Life (ITLs) will be identified within the SAFER Matrix which will require the same follow-up process associated with potential Preliminary Denial of Accreditation.

Contact us if you want to know more about how the new SAFER Matrix will affect your future accreditation process.

On July 12th at the American Society of Healthcare Engineers (ASHE) annual conference in Denver, CO George Mills, Director of Engineering for the Joint Commission, announced that the Joint Commission will be eliminating the Plan for Improvement (PFI) portion of the Statement of Conditions (SOC) starting August 1st. See the announcement from ASHE Here. Christopher Lynch. P.E., Principal with Code Red Consultants was in attendance at the presentation by George Mills. The list below summarizes some key information regarding this significant change in the compliance process:

• Why is the change being made? The change is occurring due to a Centers for Medicare and Medicaid Services rule requiring the correction of known life safety code deficiencies within 60 days of discovering them. It is worthy to note that there is a time based waiver process for items which justifiably take longer to correct.
• What happens to existing PFIs? Starting August 1st, the Joint Commission will no longer be providing life safety surveyors with access to the e-SOC information or the PFI. The PFI is now an internal tool to help facilities manage their deficiencies. There is no obligation for a facility to provide their known deficiencies to the surveyors when they arrive. Under the previous PFI process, facilities were not cited for deficiencies they proactively reported through the PFI. This is no longer the case and the Joint Commission will be employing a “See it, Cite it” approach.
• What happens if I receive citations during a survey? The facility will have 60 days to correct identified deficiencies noted during the survey. This will be done through what is called a Survey Plan For Improvement or SPFI.
• What do I do if I need more than 60 days to correct an item that is cited during a survey? If more than 60 days is needed, the facility has 45 days from the time the finding is made to submit a time limited waiver request through the Joint Commissions Salesforce portal. After submitting the request, the facility will receive a receipt that should be saved as evidence that the request is in the queue. The time limited waiver will be evaluated and approved by CMS.

These changes are substantial and eliminate the protection previously afforded to facilities which proactively identified issues and corrected them on a timeline they created. The elimination of the PFI process will lead many facilities to re-evaluate how they assess their facility for life safety code deficiencies. While there is no longer any protection for proactively identifying issues, the pain facilities will feel if they are identified on survey has been elevated. There is a time based waiver process, however those are evaluated on a case by case basis by CMS and there is no guarantee additional time will be allotted.

Our recommendation is for facilities to evaluate the timing of when they perform life safety evaluations of their facilities. The new system post August 1 will incentivize facilities to have all known deficiencies corrected. We believe this will drive facilities to perform evaluations annually rather than every three years such that the timing and resources needed to correct items can be accommodated before the next Joint Commission inspection. In addition to annual inspections, an additional evaluation in the months preceding an inspection would be advantageous to evaluate compliance of common maintenance items such as fire doors. Mr. Mills made an excellent point during his presentation that it would be wise for facilities to still utilize the PFI tool on the Joint Commission web site to keep the issues visible to hospital leadership to ensure sufficient budgets and resources can be allocated to performing corrective actions.

There will be more information to come on this topic before August 1st, but please feel free to contact us to discuss impacts on your facilities and life safety program.