Joint Commission eliminates life safety Plans for Improvement

December 19, 2025
Accreditation & Quality Compliance Advisor
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As of August 1, The Joint Commission will no longer accept hospital Plans for Improvement for life safety deficiencies identified by surveyors, the accreditor announced. Instead, all Life Safety chapter deficiencies, even those self-identified by a facility, will become Requirements for Improvements [RFI] issued by the surveyor.

All corrective actions for deficiencies will have 60 days to be fixed, unless given an extension by the CMS regional office. The six-month automatic extension for corrective actions has also been eliminated.

The change was announced at the American Society of Healthcare Engineering [ASHE] annual conference by George Mills, director of engineering for The Joint Commission, according to an ASHE advisory alert. The change comes at the request of CMS, which had asked The Joint Commission to revise its Statements of Conditions process.

 Visit here for more information on the changes.

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