Joint Commission makes major changes to Plans for Improvement

Subject Matter: Issue brief/advocacy alert | Topics: Codes and standards

The Centers for Medicare & Medicaid Services (CMS) has asked the Joint Commission to make several changes to its Statement of Conditions process, and the Joint Commission will no longer consider hospital Plans for Improvement (PFIs) starting August 1. Instead, all life safety deficiencies will need to be corrected within 60 days, although a time-limited waiver process will be available through CMS regional offices. George Mills, MBA, FASHE, CEM, CHFM, CHSP, director of engineering with the Joint Commission’s Department of Engineering, announced the major changes at the ASHE Annual Conference.


Under the new process:

  • Deficiencies will need to be corrected within 60 days of being identified unless the CMS regional office approves an extension.

  • All requests for extensions will be handled by CMS regional offices. However, the Joint Commission will allow facilities to submit requests and receive a receipt to show they are in the pipeline waiting for an extension.

  • The Joint Commission will not review open Plan for Improvement (PFI) items, and PFIs will not be a part of final reports.

The changes will be effective August 1, Mills said. The Joint Commission is an accrediting organization that has deemed authority from CMS and must meet CMS requirements. Mills said the PFI process can still be used as an internal management process.