Extension of a PFI

What is the process to extend the projected completion date of a PFI and what are the consequences if the extension is not approved?

Once a PFI has been accepted by The Joint Commission, you can extend the projected completion date beyond the initial automatic six-month extension only by submitting a request to The Joint Commission Standards Interpretation Group (SIG) engineers for consideration. To submit such an extension request, you should use The Joint Commission Online Standards Submission Form, found at http://jcwebnoc.jcaho.org/newsigsub/ sigonlineform.aspx. This form is also available in the Statement of Conditions™ (SOC) PFI menu, under “Request for Extension and Equivalencies.”  

Specific information necessary for a complete extension request includes the following:
■ Original and proposed projected completion dates
■ Brief description of the deficiency
■ Reason(s) for the extension request
■ Confirmation that the extended PFI will be given a high priority for completion
 
After reviewing your request, a SIG engineer will post an acceptance or denial on your organization’s SOC, under the PFI menu “History Audit Trail.” You must therefore give the SIG engineers access to your SOC as part of the request. If the extension is granted, the SIG engineers will also enter the PFI and modify the projected completion date to reflect the extended action. A courtesy e-mail will be sent at the same time to the contact person identified in the SOC.
 
You may be cited under TJC’s new Accreditation with Follow-up Survey rule AFS13, “The hospital has failed to implement or make sufficient progress toward the corrective actions described in a Statement of Conditions™, Part 4, Plan for Improvement, which was previously accepted by The Joint Commission, or has failed to implement of enforce applicable interim life safety measures.” This replaces Conditional Accreditation rule CON04 effective Jan.1, 2011. See your 2011 TJC accreditation manual chapter The Accreditation Process for full details. Don’t forget to develop and enforce your ILSMs for your life safety deficiencies as well.