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The Joint Commission Revises Statement of Conditions Process

Posted on September 13, 2016 in Health Law News

Published by: Hall Render


Hospitals and other facilities that are accredited by The Joint Commission work to ensure compliance with The Joint Commission’s “Life Safety” chapter, which requires compliance with the National Fire Protection Association’s NFPA 101: Life Safety Code (“LSC”).  As part of those efforts, many accredited facilities have used The Joint Commission’s Statement of Conditions (“SOC”) as a proactive management process to self-identify LSC deficiencies, establish Interim Life Safety Measures while the facility works to address the deficiency, establish a timeline for compliance and manage the activity needed to resolve the deficiency. The Centers for Medicare & Medicaid Services (“CMS”), however, required The Joint Commission to change its SOC process for deemed facilities to help ensure those facilities are in compliance with federal law. The Joint Commission implemented important changes to its SOC process beginning August 1, 2016.

Changes to The Joint Commission’s SOC

Prior to August 1, The Joint Commission did not document a facility’s self-identified deficiencies during a survey because the facility, as part of the SOC process, had already identified and was working to resolve the deficiencies. The Joint Commission required facilities to resolve the identified deficiencies within six months. CMS believes this six-month time period allowed by The Joint Commission does not comply with CMS’s survey and certification procedures in 42 CFR 488.28(d). The federal rule states a facility must resolve a deficiency within 60 days of being notified of the deficiency unless CMS grants the facility additional time.

The Joint Commission significantly modified its SOC process in order to address CMS’s concerns. If self-identified deficiencies continued to be part of The Joint Commission’s survey process, CMS would have required The Joint Commission to convert any self-identified deficiencies to requirements for improvement (“RFI”) during a survey. The Joint Commission, however, did not believe the restrictions being placed on the then-existing survey process fit the original design of their quality assessment program. The Joint Commission, therefore, removed self-identified Life Safety Code deficiencies from the survey process.  A deficiency identified by The Joint Commission during a survey will become an RFI, and the facility will need to resolve the RFI within 60 days. If a facility’s completion date extends beyond 60 days, the facility must request a time-limited waiver from The Joint Commission within 45 days from the end of the survey. The Joint Commission will review the request and, if the facility has deemed status, will submit the request to the CMS regional office for approval within the 60-day time period.

Similarly, for accredited facilities that have deemed status, The Joint Commission will submit any survey related requests for equivalency from a facility to CMS for approval. A facility may request an equivalency if a corrective action would pose a hardship to the facility and the deficiency or interim measure taken by the facility does not directly affect the safety of the facility’s patients, staff or visitors. The facility may pursue a time-limited waiver related to the equivalency request.

Practical Takeaways

The changes described above are part of a number of changes made by The Joint Commission to the SOC. The Joint Commission’s August 2016 newsletter provides additional details of the changes they have recently implemented.  A statement from The Joint Commission is available here.

Facilities that are accredited by The Joint Commission, which can include hospitals, critical access hospitals, hospice, ambulatory care and other providers, should review their current procedures for assessing fire safety risks and managing any needed plans for improvement (“PFI”) related to self-identified deficiencies. While self-identified deficiencies are no longer part of the survey process, The Joint Commission has made the PFI function of the SOC an optional management program. Accredited facilities will need to consider whether it is beneficial for the facility to participate in The Joint Commission’s now optional function of the SOC. Accredited facilities may also need to evaluate their own internal processes to ensure they are able to comply with the 60-day time limit to complete a survey related PFI, absent waiver approval by CMS.

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