Making healthcare remarkable

Managing Joint Commission Life Safety Deficiencies

PFI’s No Longer Work

Objectives

Joint Commission Preparation

Your Risk Assessment Process

Mitigating Deficiencies

Interim Life Safety Measures (ILSM)

Time Frames

Responding to Identified Deficiencies

Repairing Identified Deficiencies

Survey-Related Plan for Improvement (SPFI) Waivers

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PFI History

Prior to 2017, TJC would allow a Plan for Improvement (PFI)

If you could show proof of a workorder, you may not be cited.

Many PFIs could be fixed

You could set your timeline for corrective action

There was not a formal risk assessment process

A few months before a survey, rush to fix

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Beginning to 2017

TJC new process: “See it! cite it!”

Workorders will not save you

Cannot create a PFI or timeline to repair

Proactively need to manage and repair deficiencies quicker

A defined process as to how Life Safety deficiencies are identified through inspections

Three months before a survey will not work

Post survey – 60 days to repair or request a waiver

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Leadership Involvement

Is this how you ask for funding?

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Leadership Involvement

There needs to be open communication with your leadership team.

Need to understand that PFI no longer exist and there is only 60 days to make a repair.

This begins with budget preparation (contingency)

It is also important that leadership understand that JC reports will be longer

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Life Safety Deficiencies Policy

Do you have a Risk Assessment Policy?

Define the frequency for conducting a life safety risk assessment

Ensure ILSM is included, if needed

Both construction and routine

Important to define the term “Immediate”

What is your process to manage deficiencies?

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Risk Assessment

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• Conduct Life Safety Assessment• Identify LS Deficiencies• Create Workorder• Repair Within 24-hours• Implement ILSM • Complete Repair within 60-

Days

Risk Assessment Tool

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Risk Assessment Tool

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Risk Assessment Tool

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Risk Assessment Tool - ASHE

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Risk Assessment Tool - ASHE

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Life Safety Drawings

LS.01.01.01 EP 3

The hospital maintains current and accurate drawings denoting features of fire safety and related square footage.

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Life Safety Drawings

LS.01.01.01 EP 3

Fire safety features include the following: - Areas that are fully sprinklered/partially sprinklered

- Locations of all hazardous storage areas

- Locations of all fire-rated barriers

- Locations of all smoke-rated barriers

- Sleeping and non-sleeping suite boundaries, including the size of the identified suites (sq. ft.)

- Locations of designated smoke compartments (sq. ft.)

- Locations of chutes and shafts

- Any approved equivalencies or waivers

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Tracking LS Deficiencies

How are you tracking Life Safety Deficiencies

Workorder System

JC PFI section – JC does not have access.

Excel Spreadsheet

Other Format

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Tracking LS Deficiencies

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Tracking LS Deficiencies - ATG

ILSM Document

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ILSM Document

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Managing the Survey Process

Survey Management – Document Review Organization Have all documentation available at time of survey Walk surveyor through the documentation

Control the review Do not have the surveyor review documentation on their

own Be Confident Repeat surveyor’s question for clarification Answer only what is asked Do Not volunteer information Have support team help with any discrepancies

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Managing the Survey Process

Never volunteer LS deficiencies

Be prepared to address how you will identify and manage LS deficiencies

Ensure that ILSM’s are in place and you can explain, both past and present

Repair as much as possible before the surveyor leaves

If repairs cannot be completed before the surveyor leaves, be able to address the ILSM that will be in place until the repair can be made

Keep your leadership informed of both findings and ILSM’s.

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The Survey is Over

Deficiencies need to be completed within 60 days

If repairs cannot be completed within 60 days, request a SPFI and a time limited waiver request

Found on the JC website

Request needs to be approved by JC and CMS

Repair deficiency within limited waiver time frame

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Gary MilewskiCorporate ComplianceNovant Health(919) 817-6823