The Joint Commission has eliminated its post-survey category of “Contingent Accreditation.” Now organizations can only receive one of four decisions: Accredited, Accredited with Follow-up Survey, Preliminary Denial of Accreditation, or Denial of Accreditation.
Accreditation— Given to a facility that’s compliant with all applicable standards or has successfully addressed all Requirements for Improvement (RFI). Once the Evidence of Standards Compliance (ESC) is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.
Accreditation with follow-up survey— Given to a facility that isn’t in compliance with specific standards that require a follow-up survey within 30 days to six months. Also requires that problem areas listed in an ESC submission are corrected. Once the ESC is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.
Preliminary denial of accreditation— Given to a facility when there’s evidence of one or more of the following:
• An immediate threat to health or safety to patients or the public
• Falsified documents or misrepresented information was given to surveyors
• The facility is missing a required license or certification
• The facility is significantly out of compliance with Joint Commission standards
Additional rules for receiving a “Preliminary Denial of Accreditation” ranking have been listed in the “important updates” section of Joint Commission Connect and are as follows:
• Failing to fix all Requirements for Improvement (RFI) after two opportunities to submit ESCs have passed
• Failing a second Medicare Deficiency Survey for not meeting a Condition of Participation or a Condition Level Deficiency
• Evidence reveals patients have been put in jeopardy due to potential fraud or abuse committed by the organization
A Preliminary Denial of Accreditation (PDA 02) decision is made; organizations are now expected to submit a Plan of Correction (POC) within 10 business days of the final report’s posting. After which, there’ll be a survey within two months to validate the implementation of the POC. This will be done in lieu of submitting ESC within 60 days.
For PDAs, facilities can appeal The Joint Commission to review this decision.
Denial of accreditation - A facility is completely denied accreditation. This happens when a facility:
• Doesn’t to pay its survey or annual fees
• Refuses to let The Joint Commission conduct a survey
• Fails to address the conditions of their Accreditation with Follow-up Survey status
• Fails to submit an ESC
At this point, there are no more appeals or reviews that a facility can use to stay accredited.
Finally, The Joint Commission’s governance structure has changed. Now, decisions on accreditation matters will be made by an executive team rather than an Accreditation Committee. The executive team is now in charge of making accreditation decisions, considering survey reports, follow-up activities, staff recommendations, and any unusual problems raised by the organization seeking accreditation.
Check out Briefings on Accreditation and Quality to learn more about the importance of avoiding denial of accreditation.