Extension for SOC-PFI

What are the conditions allowing an extension of an SOC-PFI?  Does it apply to all PFIs?



The Joint Commission (TJC) allows organizations to exceed their Statement of Conditions (SOC) Plan for Improvement (PFI) “projected completion date” by up to six months on previously accepted or original PFIs without any penalty. Note: This same six-month grace period cannot be applied to approved PFI revision requests or extensions. (See Environment of Care® News, July 2006, Vol. 9, No.7.) TJC looks for sufficient progress in completing PFI items at the time of survey. Failure to make “sufficient progress” toward the corrective actions described in the approved PFI could result in a recommendation of Conditional Accreditation. (See Conditional Accreditation rule CON04 in The Accreditation Process chapter of the accreditation manual.)

If an organization requests an extension to its originally listed projected completion date before the six-month grace period expires and before their survey, TJC may typically grant a one-time extension. If the six-month grace period has expired, and the organization requests an extension prior to survey, TJC may still grant a one-time extension. However, in this latter case, since the organization would then be out of compliance, it may be cited at Leadership standard LD.2.20 EP2 (attributed to management issues) or LD.3.80, EP4 (attributed to lack of resources). Also, PFI entries that have excessively long projected completion dates or list non-LSC deficiencies could be scored at LD.4.50, EP3. (PI activities are not reprioritized.)