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[thumbnail alt=”Tim O’Rourke, CHFM” type=”img-thumbnail” alignment=”alignright” image=”×300.jpg” ]Tim O’Rourke, CHFM, B&A Engineer[/thumbnail]Barrins & Associates engineer Tim O’Rourke, CHFM has an alert for our psychiatric hospital clients surveyed under Joint Commission Hospital standards. Tim has worked with many of you over the years on mock surveys and compliance with the Life Safety and Environment of Care standards. He wants you to be aware of upcoming changes to the TJC survey process and survey report. These changes relate to two areas:

  • Plans for Improvement (PFIs) that hospitals develop when they identify an area of non-compliance with the Life Safety Code that cannot be resolved within 45 days.
  • The approval process for Life Safety Code equivalencies

TJC is making these changes to align with CMS requirements and maintain its deeming authority to survey hospitals for compliance with the CMS Conditions of Participation for Medicare and Medicaid. The table below summarizes the current process and the changes that go into effect July 1, 2014.

For more detail on how TJC will be handling overdue PFIs, see the Joint Commission Online article “Notice: Overdue PFIs previously accepted during survey must be addressed by July 1, 2014

Tim recommends that you share this important information immediately with your leaders and managers responsible for EOC and Life Safety compliance at your hospital. You can also contact Tim directly with any questions you have about these changes and how they affect your hospital:


Change to TJC Survey Report Current Process Change effective July 1, 2014
Added a new section: Open Plans For Improvement (PFIs) The organization creates a PFI to address noncompliance with life safety requirements

The open PFI does not appear in the decision report.

The organization completes the work identified in the PFI.

Open PFIs will be listed in the decision report.

ESC follow-up is not required for open PFIs, however, the organization will still need to complete any required work identified in a PFI.

Failure to resolve a PFI may result in an on-site survey.

Life Safety Code® equivalencies to be approved by the CMS Regional Office Equivalencies are used when an organization uncovers an existing Life Safety Code® deficiency that cannot be corrected without major construction. In these cases, the organization may ask for approval of an “equivalency” by demonstrating that alternative building features exist that comply with the intent of the Life Safety Code.

The Joint Commission reviews and approves equivalency requests.

The Joint Commission will review the equivalency request and forward it to the CMS Regional Office for final action.

The organization and The Joint Commission will receive a response to the request from the CMS Regional Office.

Appropriate Interim Life Safety Measures (ILSM) will need to be in effect until the final response from the CMS Regional Office is received.