Compliance News: PFI Extension Requests

By Dean Samet, CHSP

The Joint Commission allows organizations to exceed their electronic Statement of Conditions™ (eSOC) Plan for Improvement (PFI) “projected completion date” by up to six months on previously accepted or original PFIs without any penalty. However, once that PFI has been accepted by TJC, the organization can further request a one-time extension when it appears that they are going to exceed their projected completion date(s).

The following information is required to be provided:

• Original and proposed projected completion date(s)
• Brief description of the deficiency or deficiencies
• Reason(s) for the extension request
• Confirmation that the extended PFI will be given a high priority for completion

PFI extension requests are to be submitted to TJC’s Standards Interpretation Group (SIG) engineers for their consideration via The Joint Commission Online Standards Submission Form found at: http://jcwebnoc.jcaho.org/newsigsub/sigonlineform.aspx.  This form is also available in the electronic Statement of Conditions™ PFI menu under “Requests for Extension and Equivalencies.”

 

SIG engineers will post an acceptance or denial of the PFI extension request on the organization’s eSOC under the PFI menu “History Audit Trail.” If and when an extension is granted, SIG engineers will enter the organization’s eSOC/PFI and modify the projected completion date(s) and any revised actions as necessary. They will also send a “courtesy” e-mail to the contact person identified in the eSOC.

 

TJC surveyors look for “sufficient progress” in completing PFI items at the time of survey. Failure to make sufficient progress toward corrective actions described in the approved PFI (previously accepted; original; or accepted extension) will most likely result in a recommendation of Accreditation with Follow-up Survey per 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 or enforce applicable interim life safety measures.”