The Greeley Company
July 13, 2016 6 Min Read

One Anticipated Move and One Unexpected Departure: The Life Safety Code takes on a new perspective

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For those of you who closely follow the ebb and flow of the physical environment regulatory compliance season, 2016 has been an unusually busy year, particularly over the last couple of months or so.

To start with, in a move that had been anticipated for quite some time, CMS announced on May 4th that it was formally adopting the 2012 edition of the NFPA 101 – Life Safety Code, effective July 5, 2016 (see press release here). Interestingly enough, while the industry had been waiting (pretty much since 2012) for this to happen, the announcement still came as something of a surprise—albeit a pleasant one.

To frame the full adoption of the 2012 Life Safety Code, due to the provisions of various Categorical Waivers, CMS had already allowed hospitals to adopt some specific elements of the 2012 Life Safety Code, including flexibility in corridor furnishings, designation of suites, and some other elements. (You can find information on the waivers here, but I suppose you don’t have to worry too much about them at this point as full adoption of the 2012 renders the waivers—including the related presentation of documentation at the commencement of the survey process—pretty much moot.) There was a fair sigh of relief from the plant ops/facilities portion of the industry, as this was largely seen as a move forward, though close examination of the 2012 Life Safety Code revealed that a lot of the requirements that have gotten hospitals into trouble in the past are very much the same, and are likely to continue to be vulnerabilities for the foreseeable future. Fire and smoke protection building features (fire doors, smoke doors, fire walls, sprinkler systems, etc.) are still going to require the same degree of attention as they had in the past. In fact, in the case of fire doors, there is now a requirement that all fire doors be inspected for proper operation at least annually. While this has always been a preferred practice, it was optional – but no more. At any rate, while adoption of the 2012 Life Safety Code provided facilities with some flexibility, many of the existing challenges to managing the life safety components of the physical environment remain intact.

As a further note relative to the adoption of the 2012 Life Safety Code, for the purposes of survey preparation and all its nuances, while adoption of the 2012 Life Safety Code was effective July 5, 2016, formal implementation of the Life Safety Code from a survey perspective will not occur until November 7, 2016.

Of particular interest to those of you with ambulatory surgery locations, CMS published a correction in the Federal Register on June 30 (details here) stating that Part 482.41 of the Conditions of Participation is being changed so that all (and that means “all”—new and existing facilities) hospital-based outpatient surgical departments must meet the provisions of the Life Safety Code applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. Strictly speaking, under the Life Safety Code, these types of ambulatory surgery settings could be considered under the business occupancy designation if the facility has less than four patients rendered incapable of self-preservation. This means that you may have to be thinking about evaluating any of your small hospital-associated medical office buildings that are providing minimally invasive surgical procedures.

Now, we fast-forward to July 12, when (fairly late in the day), the American Society of Healthcare Engineers (ASHE, a personal membership group of the American Hospital Association) issued an advisory to members notifying them that, effective August 1, 2016, The Joint Commission is eliminating the Plan for Improvement (PFI) process as a means of managing Life Safety Code deficiencies that cannot be immediately corrected and that will take longer than 45 days to resolve.

In place of the PFI process is an expectation for all life safety deficiencies to be corrected within 60 days of identification or a request (and subsequent approval) made to the regional CMS office for a time-limited waiver extending the completion date. So, the process as outlined in the ASHE Advisory goes a little something like this:

  • 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.

From current appearances, this move not only infinitely complicates the management of life safety deficiencies over time; it also appears to be driving completion of all current PFIs. As of this writing (the morning of July 13th), there has been no official release of information from The Joint Commission, so it’s tough to get a clear “read” on this part of the puzzle (and make no mistake, this is a puzzle with a lot of pieces). While we are waiting to see what the official word from TJC might include, I suspect it will be more or less reiterative of the information conveyed in the ASHE e-blast. The critical point for organizations undergoing survey after August 1 is whether George Mills’ statement that the survey will not include review of any open PFIs and that not including them in the final report is a tacit allowance for the process to continue until an organization undergoes a CMS survey. That said, as near as I can tell, there’s nothing to prevent a surveyor from looking at the e-SOC at their hotel, inquiring generically about any existing PFIs, and then using that as a starting-off point for deficiency identification. At this point, I don’t know that I would recommend closing out all the open PFIs, but it would at least prompt them to have to ask the question – do you have any LSC deficiencies that were identified more than 60 days ago, and since you can’t really fib to the surveyors, you would have to come clean, so to speak.

When I was asked for my initial thoughts upon learning of this change, there were several expletives that came to mind (and I suspect they are coursing through the collective craniums of your plant ops folks as well), but I do know that a fundamental means of managing conditions in the physical environment has pretty much been ripped from our hands. I guess we could look at this as one more piece of the TJC “becoming more like CMS” movement that has been afoot for quite a few years now. Or maybe, as CMS never really accepted the PFI process as an alternative means of LSC compliance, they finally told TJC to cease and desist.

Now before you get too, too panicky, apparently we will still be able to use the PFI process as an “internal management process,” so everything’s good – right? I guess we’re going to have to wait and see how this all unfolds in the field, but I have a sneaking suspicion that, of all the changes we’ve encountered this year, this one is going to result in the greatest amount of disruption, at least in the short term.

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