Life Safety Code
December 04, 2008

Welcome to the PFI Change Request & Equivalency Request Information

To accurately respond to your Statement of Conditions™ (SOC) request, the Standard Interpretation Group (SIG) Engineers require you to follow the submittal process exactly. Any deviation will result in our denying your request and requiring your re-submittal.  All references to the Life Safety Code (LSC) are to the NFPA 101-2000 edition.

Two types of requests that can be made include:

  1. Request to have an Extension to an open accepted Projected Completion Date

    a. NOTE: open Plan for Improvement (PFI) items that have not been
         “accepted” by a Joint Commission Surveyor may be modified by the
         organization without involving the Standard Interpretation Group Engineers.
  2. Request to modify values in an open accepted PFI

The submission process for one of the requests from above is to use The Joint Commission Online Standards Submission form.  While completing the Online Standards Submission form, supply all required information (identified with a red *), and use the following information as described:

  1. Select “Other” for the Subject of Standard
  2. Select “Other” for Accreditation Manual referred to in question
  3. In the text box marked “Please enter your question here (limited to 4000 characters)” make sure your first line is: PFI Change Request.

To access the organizations SOC, SIG Engineers will require the following:

  1. Health Care Organization (HCO) number (located in the title section of the SOC)
  2. Name and location of the organization
  3. Name, title and contact (phone and email) information of the individual requesting the change
  4. Authorization to SIG Engineering enter the updated information directly into your SOC
  5. Unique Identifier (may be grouped if similar issues)
  6. Specifics related to the request: 

a.  Original and Proposed Projected Completion Dates
b.  Brief description of the deficiency
c.  Why the extension request is being made
d.  Application of Interim Life Safety Measures (ILSM) policy
e.  Confirmation that the PFI will receive high priority to complete as requested 
 

Traditional Equivalency Request [WRITTEN SUBMITTAL]

  1. Identify each deficiency.
    A.   Reference both The Joint Commission standard and Element of 
          Performance and the applicable NFPA 101®-2000; Life Safety Code®
          (LSC) paragraph.
    B.  State the intent of the LSC.
  2. Propose an alternate solution.
    A.  Explain proposal in writing.
    B.  Provide detailed drawings showing existing conditions and proposed  
          solution (maximum size of unfolded drawings - 11 in x 17 in).
    C.  Indicate the total cost and describe the source, availability, and 
          commitment of funds for the proposed alternate solution.
    D.  Provide a timetable of events from present through completion.
  3. Implement Interim Life Safety Measures (ILSM) as appropriate as per organization policy
  4. Have one of the following certify, in writing, that to the best of their knowledge, your proposed alternate solution meets either the intent of the LSC identified in 1A above or will provide an equivalent level of life safety:
    A.  Fire protection engineer
    B.  Registered architect
    C.  Local authority having jurisdiction (over enforcement of fire safety).
  5. Submit to the address given below.

Fire Safety Evaluation System Equivalencies (FSES) Request [WRITTEN SUBMITTAL] 

  1. Perform the FSES equivalency evaluation. Reference document is NFPA 101A-2001, Alternate Approaches to Life Safety. 
  2. Complete all FSES Worksheets for every zone in the healthcare facility. Evaluate each zone as it presently exists. Drawings, SOC, and LSC deficiencies must support point values selected. (See NFPA 101A-2001, 4.3.2)
  3. List all LSC deficiencies (include LSC reference numbers) identified within the zone during building assessment.
  4. Provide a floor plan. Unfolded attachments must not be larger than 11 in x 17 in. Indicate zone boundaries. Identify or illustrate (provide a legend) each of the following features of life safety that exists and where credit is taken on FSES Worksheet 4.7.6: direct exits, exit stairs, horizontal exits, 2-hr fire rated separations, or smoke barriers/partitions.
  5. Complete FSES Worksheet 4.7.10 for each building containing one or more zones being evaluated.
  6. Determine if an equivalent condition exists:
    A.  Review FSES Worksheet 4.7.9 for each zone being evaluated. Any FSES
          Worksheet 4.7.9 containing no response indicates that an equivalent
          level condition does not exist in that zone.
    B.  Review FSES Worksheet 4.7.10 for each building containing zones being
          evaluated. Any FSES Worksheet 4.7.10 containing a Not Met response
          indicates that an equivalent condition does not exist in any zone within
          that building.
  7. Those zones having all Yes responses to FSES Worksheet 4.7.9 and either Met or Not App. responses to FSES Worksheet 4.7.10 indicate that an equivalent condition presently exists.
  8. Provide authorization for SIG Engineers to review the SOC, Plan for Improvement (PFI) for each zone where an equivalent condition does not presently exist.
  9. Provide list of related PFIs
  10. FSES Worksheet 4.7.7A. The column labeled “Condition After PFI” must validate the numeric values that will result when the PFI is completed.  Any numeric increase in “Condition After PFI” from “Condition Before PFI” must be supported by the proposed actions.
  11. All above steps must be accomplished using the most current information available. Do not submit an FSES equivalency request where survey or evaluation information is more than one year old. Drawings and BBI must be current and accurate but are not subject to the one year restriction.
  12. Submit to the address given below.

Mail all submissions to:

The Joint Commission
Standards Interpretation Group
Engineers
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181

Note: Equivalency requests will be returned if the above procedure is not followed or the information submitted is incomplete.

NOTE: EXECUTIVE SUMMARY
Traditional Equivalency and FSES requests must be submitted in writing as discussed above.  An Executive Summary must be included that provides appropriate information, including the deficiencies and related LSC references, mitigating information related to the equivalency, evidence of compliance, and assurance that all related PFIs and ILSM will be addressed as a high priority.