Healthcare News & Insights

Four regulatory changes impacting your compliance

Astute healthcare providers know compliance efforts can easily deteriorate unless they pursue survey readiness 24/7. Those days when you could wait to tackle compliance issues 12 to 18 months before a survey are long gone. In this guest post, Larry LaCombe, VP of program management and facilities compliance at a company that specializing in facilities management, safety, environment of care, emergency management and compliance, details regulatory changes facilities need to make part of their compliance program.


Integrating regulatory mandates into daily practices and using the entire two-to-three-year timeline between surveys to address improvements isn’t just critical for keeping your accreditation, it’s essential for maintaining a healthy budget (and your sanity). In the context of The Joint Commission (TJC), this means keeping informed of evolving standards and staying vigilant to spot problems long before a surveyor does.

Below are four regulatory changes you must incorporate into your organization’s compliance efforts:

1. SAFER™ Matrix for real-time events in facilities

One sweeping change to TJC survey process is a new scoring approach for real-time events – Survey Analysis for Evaluating Risk (SAFER). Before 2016, TJC scored deficiencies using a set of predetermined categories. Now, a surveyor will judge the real-time events they observe in the facility and rate them on the SAFER matrix: how likely a deficiency is to cause harm to patients, staff or visitors, and its pervasiveness within the hospital.

Post-survey, all deficiencies cited in the SAFER matrix become Requirements for Improvements (RFIs), which must be corrected within 60 days.

2. Plans for Improvement (PFI) process no longer recognized

The new 60-day timeline is part of the changes TJC is making to the Statement of Conditions (SOC) process. Since 1995, healthcare organizations used the SOC to manage and inform TJC about their self-identified deficiencies.

TJC would then allow the healthcare organization to craft its own PFI and determine the time needed to correct these self-identified Life Safety Code (LSC) issues with very flexible timelines – a six-month grace period, plus the ability to request a six-month extension. TJC wouldn’t include self-identified deficiencies as RFIs during the survey process.

That’s all changed. TJC no longer considers the PFI process for its Life Safety chapter requirements.

You’re still required to maintain a safe environment, and ensure Fire and Life Safety Protective features keep patients, staff, visitors and buildings safe from the threat of fire. This means your organization must continually assess the protective features of your buildings through numerous processes: environmental tours, life safety assessments, formal rounds and so on. Deficiencies identified during these processes must be managed continually until remedied.

Note: Although TJC no longer recognizes PFIs, they continue to offer their online process to help you manage your self-identified deficiencies. At no time, however, should your healthcare organization provide TJC with a list of your self-identified deficiencies. TJC will gather this information as RFIs during the survey process.

3. Deficiencies must now be corrected within 60 days

We’ve already touched on the shortened timeline for correcting deficiencies: from six or more months to just 60 days now for LSC deficiencies identified as RFIs at the time of a survey. If an RFI requires corrective action beyond the 60-day Evidence of Standards Compliance, your organization can request an extension, which is much harder to secure these days.

First, your organization must create a Survey-Ready Plan for Improvement (SPFI) through TJC’s web portal (SPFI tab). Once that plan is created, your organization must then request an extension from the Centers for Medicare & Medicaid Services through a Time Limited Waiver process. This request should be made through the TJC’s eSOC web portal within 30 days from the last day of the survey.

Whether your LSC deficiency is self- or survey-identified, your organization will need to manage the remediation process. This can be done through TJC’s PFI process, a Computerized Maintenance Management System (software commonly known as CMMS) or alternative programs. The only exception is if the survey related LSC deficiencies requiring additional time through TJC’s Survey Related Plans for Improvement process for requesting Time Limited Waivers is within 30 days.

4. Life Safety Code evolved to include new comprehensive standards

Not only has the way your organization finds, reports and corrects deficiencies changed, but so has the Life Safety Code. CMS has adopted the 2012 edition of NFPA 101 and its referenced publications.

This change means new, more comprehensive fire and life safety standards, like establishing a fire watch or evacuating the facility if sprinkles are out of order for more than 10 hours, or the mandate that all buildings taller than 75 feet must install an automatic sprinkler by 2028.

How to make changes

These are big changes with big implications for healthcare organizations, and it’s easy to feel overwhelmed as you work to hold on to your TJC accreditation. As other healthcare facilities have navigated these changes and achieved 24/7 survey readiness, they’ve found it’s helpful to break down the process into four areas:

  • Stay informed – Performing ongoing assessments will help you identify risks, issues and blind spots.
  • Stay organized – Ensure your documentation is organized, consistent and up-to-date by creating and enforcing policies for how you manage documentation across the organization.
  • Communicate clearly – Staff will better incorporate compliance standards into daily practices if they understand them clearly.
  • Get expert support – No one expects you to know everything. The most successful hospitals are those who know their limits and don’t waste time reinventing the wheel. Rather, they develop internal compliance training programs or partner with a trusted expert to do so.

Hospitals are places of unpredictability. Having the proper processes and know-how will help you bounce back from setbacks more quickly, efficiently and affordably.

As you pursue 24/7 survey readiness, you’ll find it’s much easier to nail your next survey without losing sleep over it.

Larry LaCombe is the VP of program management and facilities compliance at Medxcel Facilities Management, specializing in facilities management, safety, environment of care, emergency management and compliance. Medxcel Facilities Management provides healthcare service support products and drives in-house capabilities, savings and efficiencies for healthcare organizations that, in turn, improve the overall healing environment for patients and staff. 

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