The Preliminary Planning Session
How Should I Prepare for the
Preliminary Planning Session?
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The Preliminary Planning Session
 Occurs on the morning of the first survey day
 Will be performed by the surveyors “alone”
 Will create strong first impressions (“Blink!”)
 Will impact the rest of the survey!
 Will be document-based (documents should
always be up-to-date and ready)
 Hospital must be prepared for this!
 Should trigger the “Rapid Response Team”
 The Life Safety Surveyor may come at a later time
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The Preliminary Planning Session
Documents to be reviewed include:
 The six required management plans plus the “EOP”
 Safety committee minutes from the last 12 months

The most recent annual effectiveness evaluations from each “EC”
area and Emergency Management
 Statement of Condition documents (reviewed by the LSS)
 Fire plans and fire drill evaluations
 Interim life safety measures policy
 Safety officer signed appointment letter with intervention
authority statement
 Categorical waiver letter, if applicable
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The Management Plans
Expectations Include:
 A description of the program, not a rewrite of the program!
 Consistent format, in a labeled, tabbed binder
 A list of applicable facilities to avoid multiple plans
 A description of each “element of performance”
 Responsibilities from governing body to staff
 Performance improvement and training information
 Risk assessment and ICES information
 An annual review by the safety committee
Note 1: Emergency Management requires an Emergency
Operations Plan (EOP), not a management plan
Note 2: “High Risk” plans include safety, hazmat, biomed, utilities
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The Management Plans
Best Practices Include:
 Cross-reference or cite supporting policies that already exist
 Note when the AHJ has a stricter interpretation or code reference
 Reference other related Joint Commission standards
(example: HR, LD, PI, IM standards)
 Distribute plans to each applicable “off-site” facility
 Don’t just list or restate the required standards or EC numbers
 Consider the plans to be a “roadmap” to effective EC
management
 Consider appendix documents that reference applicable policies,
define responsibilities and list performance indicators
Note: Refer to additional information regarding “EC management
Plans” in the June, 2013 issue of Perspectives
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The Emergency Operations Plan
Expectations Include:
 The Emergency Operations Plan (EOP) is not a management
plan, but a robust description of emergency operations procedures
and information
 At a minimum, the EOP should describe the following:
1. The Hazard Vulnerability Analysis (HVA)
2. Mitigation, Preparedness, Response, Recovery (MPRR)
3. The Incident Command System structure (ICS)
4. The six critical core areas of emergency management, including:
communications, resources and assets, safety and security, staff roles
and responsibilities, utilities and patient management
 Also include a description in the EOP of emergency drills and
reference emergency codes, procedures, and other materials that
exist and supplement the program
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The Safety Committee
Best Practices Include:
 Leadership representative (VP-level or equivalent) present
at every meeting
 Multi-disciplinary membership
 Attendance of standing members at least 70%
 Meet often enough to limit meeting time to 1 hour or less
 Document and distribute meeting minutes within two
weeks of the meeting and use the C-R-A-F format
 Use dashboards or spreadsheets to track regulatory and
performance improvement data
 Track the resolution of issues with a monitoring chart
 Use the meeting time to solve problems, not to review data
or information that does not require any action
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Safety Committee Issue Monitoring
Safety Committee Issue Monitoring Sheet
Issue
Number
10-17
10-23
10-26
11-01
11-02
11-03
11-04
11-05
11-06
11-07
11-08
11-09
11-10
11-11
Issue Description
Jan
Feb
Mar
Fire exit plans
Safety manual
In-services
Disaster reports
Recall sheet
Rear parking
OB project
Sharps in trash
Slick pavement
Snow removal
Telephone system.
Haz Com
Fire reports
Rehab door
F
F
T
P
P
P
P
P
F
C
F
F
T
T
F
F
P
P
P
C
Apr
May
Jun
Jul
Aug
F
R
R
F
V
R
C
C
F
P
P
P
Key to issue numbers: year of issue initiation followed by issue number in committee minutes
Key to action: P = problem initiated; F = follow-up; R = recommendation; T = tabled;
NA = no action; V = vote taken; C = complete
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Sep
Oct
Nov
Dec
Annual Evaluations
The written Annual Evaluations must include the
following sections:
SCOPE - What is being evaluated?
OBJECTIVES - What are the numerical goals/
benchmarks?
PERFORMANCE - What does the data show?
EFFECTIVENESS - How does the performance
(data) compare to the objectives?
WHAT NEXT? - What objectives do we define for
next year, based on this year’s performance?
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Annual Evaluations
“Best Practice” Guidelines for the Evaluations
 Demonstrate that the program has improved
 Provide numerical data
 Demonstrate “effectiveness” rather than “busyness”
 To effectively communicate the report to others, include a
narrative explanation, spreadsheets and graphs and charts
 Indicate whether the regulatory and performance improvement
goals and objectives have been “met” or “not met”, with a clear
method of determination
 Include goals and objectives for the following year, based on
the results of the previous year
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Annual Evaluations
Additional “Best Practice” Guidelines
 Document evaluations for every “EC” area, and Emergency
Management
 Create the evaluations as soon as possible at the end of the
fiscal or calendar year (within 30 days, if possible)
 Review and approve by the Safety Committee (within 60 days)
 Review and approve by the Governing Body (within 90 days)
 Re-read the annual evaluations before the survey to be prepared
for the Physical Environment Interview session
 The annual evaluations are a “Direct Impact” score
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The Statement of Conditions Review
LS.01.01.01: SOC and Life Safety Code
 The SOC completion will be verified through the
Joint Commission Connect site (BBI’s and PFI’s)
 Have the SOC notebook available for review
 The PFI documents from the previous survey
may be reviewed to verify completion of
deficiencies (have them available, if requested)
 The compartmentation drawings will be
reviewed to assist in planning the facility tour
 Life Safety Code compliance will be verified
during the facility tour
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The Statement of Conditions
What is the SOC?
The Statement of Conditions (SOC) is a document that is required to
be completed by every healthcare facility that applies for accreditation
by the Joint Commission. It references the *2000 edition of the Life
Safety Code and consists of the following sections:
 Basic Building Information (BBI) Form – electronic on Connect site
 Life Safety Assessment (LSA) Form – not on Connect site
 Plan for Improvement (PFI) Form – electronic on Connect site
*Note 1: The Joint Commission permits other LSC editions to be
selected, but the entire edition must then be followed; CMS also
requires compliance with the 2000 Life Safety Code
Note 2: It is likely that the 2012 Life Safety Code will be adopted by
CMS and the Joint Commission in 2015
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The Statement of Conditions
SOC Notebook (Best Practice)
 A SOC notebook is strongly recommended to contain “hard
copies” of the SOC documents
 The notebook should include at least the following sections:
Section 1: The SOC policy and responsibility statement
Section 2: Current copies of the downloaded BBI forms
Section 3: Accurate, color-coded compartmentation prints
Section 4: The latest, completed LSA-type document
Section 5: Current and previous, downloaded PFI forms
Section 6: Any correspondence with the Joint Commission,
including equivalencies, letters and emails
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The Statement of Conditions
Why Should I have an SOC Policy?
 The SOC policy describes how the Statement of Conditions
program is organized for the facility
What Should the SOC Policy Include?
 Who is responsible for completing and maintaining the SOC
 How often the SOC documents are reviewed
 Who reviews the SOC documents for timeliness
 PFI guidelines (when does a work order become a PFI?)
 Whether a BMP is implemented
 Whether an above-the-ceiling program is in place
 How the SOC documents are organized
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The Statement of Conditions Document
The current Statement of
Conditions “hard copy”
document is dated 5/2004
and can still be
downloaded as a pdf file
from JointCommission.org
for the LSA form only (do
not use the BBI or PFI
“hard copies” – they are
obsolete)
Note: Most organizations
do not use this document
at all!
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Statement of Conditions Document
Notes About the e-BBI Form
 List on the e-BBI cover page every occupancy that will be
surveyed, even for business occupancies (make sure that the
BBI and survey list match!)
 The e-BBI questionnaires are only required for ambulatory
and healthcare facilities, not business occupancies
 Fill in the e-BBI comments section regarding SOC preparer,
location of building drawings, mixed occupancies, equivalencies,
special building features or local AHJ requirements, including the
CMS “Categorical Waivers”
 If multiple occupancies are entered, the greatest percentage
defaults to the BBI form, so multiple BBI entries are required
 Be sure to print the electronic version of the BBI form at least
annually so that a “back-up” is available, and place a copy in the
SOC Notebook
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Statement of Conditions Document
Compartmentation Requirements
Mixed Occupancies: (LSC sections: 19.1.2.1, 19.1.2.2)
Sections of health care facilities shall be permitted to be classified
as other occupancies (such as business), provided that they meet
the following conditions:
1)
They are not intended to serve health care occupants for purposes
of housing, treatment, or customary access by patients incapable
of self-preservation
2)
They are separated from the health care occupancy by a fire rating
of at least 2 hours
3)
The facility is not intended to provide services simultaneously for
four or more health care patients who are “litterborne”
4)
Separation between ambulatory and business occupancies only
requires a 1-hour rating (LSC: 21.1.2.1)
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Statement of Conditions Document
e-BBI Form – Buildings
Be sure to complete for all
healthcare and ambulatory
facilities
Optional for business
occupancies, but strongly
suggested to include the
cover page to indicate
“surveyable facilities”
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Statement of Conditions Document
e-BBI Form – page 3
“Previous inspections” data provides
valuable information to the survey team!
Be sure to list local or regional
requirements (example: limited
generator testing due to high pollution
days) in the “Comments” section at the
bottom of the form as well as other
requested information, including: 1)
location of the compartmentation
drawings; 2) e-SOC preparer; 3) mixed
occupancies, and; 4) equivalencies or
issued variances, including CMS
“Categorical Waivers”
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Statement of Conditions Document
Life Safety Building Compartmentation Drawings
Typical line colors might include:
Blue – smoke barrier
Green – 1 hour fire wall (typically a
hazardous area)
Red – 2 hour fire wall
Note 1: A color-coded drawing is “best
practice”
Note 2: Be sure to indicate the following
features on the drawings:
 Hazardous areas
 Smoke/ fire barriers
 Suites w/ sizes, other information
 Linen/ waste chutes, shafts, chases
 Exits
 Sprinkled/ non-sprinkled areas
 Approved equivalencies
 A legend with fire safety features
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Statement of Conditions Document
LSA Form (is not electronic):
 Is a voluntary assessment tool,
although some assessment is required
at least annually
 Is not required for “Business
Occupancies”
 The Joint Commission surveyor
normally expects some type of form,
document or evaluation to be completed
 Dated 5/2004, so a cover sheet that is
signed annually is recommended
 Can still be downloaded from the Joint
Commission home page website
JointCommission.org (type “Statement
of Conditions” in the search box)
 Can use other assessment tools (2011
form) or checklists for the LSA
 Comments in LSA must match PFI
deficiencies
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Statement of Conditions Document
LSA Documentation Options:
 Can manually complete the 2004 LSA form available on the Joint Commission home
website (JointCommission.org) in Adobe format
 Can complete the updated 2011Joint Commission
questionnaire form available from the “EC Essentials” book
 Can create a new form or process for internal use
 Can contract with an outside vendor
May, 2004 Form
2011 Form
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Statement of Conditions Document
Notes About the PFI Forms
 The forms should not be used for “operational deficiencies”, such as
exit lights burned out, doors out of minor adjustment or small
penetrations that can be easily filled – these should be completed using
the routine work order system
 The normal “trigger time” from a work order to PFI is 45 days
 Document the “PFI’s” on a continuing basis – be sure that the PFI log
is up-to-date and ready to be reviewed by the surveyor
 Don’t forget to enter the projected start and completion dates and the
actual completion date
 Be sure to document an ILSM evaluation for every PFI!
 Failure to meet the completion dates without a delay approval results
in Contingent Accreditation 6 months after the projected completion
date has passed!
 If applicable, keep any previously signed PFI copies available
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Statement of Conditions Document
The second page for the
electronic PFI forms is used to
indicate the deficiency resolutions
Don’t forget to complete all of the
requested information, including
the proposed action, source of
funds and the projected start and
completion dates
The projected completion dates
can be altered until they are
“frozen” before or during the
actual survey!
Be sure to check “YES” on the
form to indicate that interim life
safety measures (ILSM) have
been evaluated for the PFI
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Statement of Conditions Document
Changes to the SOC Process – effective 7/1/2014
 Open PFI’s will now be listed in the final decision report, so
will be available to anyone who has access to the report
 Failure to resolve a PFI beyond the 6-month “grace” period
will result in a phone call from the Joint Commission and a
possible on-site survey if it is not resolved in a timely basis
 Once a delay for a PFI is granted, the 6-month grace period
is no longer applicable!
 Equivalencies that are requested from the Joint Commission
will now be forwarded to the CMS regional (state) office for
review and possible approval – the Joint Commission will no
longer issue equivalencies unless approved by CMS!
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The Safety Officer Appointment
 Should be in a letter format
 Should identify an individual (or multiple people) by
name
 Must include an “intervention authority statement”
 Should be signed by the organization CEO and
CMO if they are on the same organizational level
 Can be signed by the Governing Body President to
indicate additional organizational support
 Only requires a re-issue if any individuals change
positions
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The Preliminary Planning Session
Questions?
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