Life Safety (LS) (Hospital and Hospital Clinics / Hospitals)
Plan For Improvement (PFI) - Scope/Quantity
Modify | April 11, 2016
What is the purpose and management requirements of the Plan For Improvement (PFI) process?
The Plan For Improvement process is to be used to identify only Life Safety Code (NFPA 101 - 2012 edition) deficiencies, and any deficiencies associated with mandatory references found in Chapter 2 of NFPA 101- 2012 edition. The number or lack of PFIs, and the nature of the PFIs are unique to the organization's circumstance. The PFI process was created to allow organizations to self assess for LSC deficiencies and create a plan for correction or equivalency. All PFIs must have an associated Interim Life Safety Measures assessment to determine if mitigating activities (for example, additional surveillance, fire-fighting equipment, training/awareness, etc.) are needed to compensate for the structural or system deficiency defined by the PFI. The Joint Commission will entertain requests to extend projected completion dates if warranted. Failure to make progress in accordance with the established schedule for a previously accepted PFI, or failure to document ILSM assessment for a PFI may result in an accreditation with follow-up survey decision. Surveyors evaluate both closed and currently open PFIs for content. Surveyors check both closed and open PFIs during building tour to evaluate how well the organization is managing the PFI process. It is important that PFI scopes are specific to the deficiency and identify the location of the deficiency. General statements of deficiency scope and location of a deficiency are not acceptable. Documenting PFI designated deficiencies on floor plans, spreadsheets, or other detailed means may be a helpful tools to achieve the specificity required. [LS.01.01.01]
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