Accreditation is awarded to a health care organization that is in compliance with all standards at the time of the on-site survey or has successfully addressed all requirements for improvement (RFI) in an Evidence of Standards Compliance (ESC) submission.
Provisional Accreditation results when an organization fails to demonstrate resolution of all RFIs in an ESC or Measures of Success (MOS) submission or meet all requirements for timely submission of data and information to The Joint Commission.
Medicare Condition-Level Deficiency Follow-Up Survey results when an organization has one or more Conditions of Participation (CoPs) scored as a Condition-level deficiency. This rule does not apply to organizations that are not currently Medicare certified.
Conditional Accreditation results when a health care organization fails to resolve the requirements of a Provisional Accreditation status or was in substantial noncompliance with applicable Joint Commission standards. The organization must remedy identified problem areas through the submission of an ESC and subsequently undergo an on-site follow-up survey. Conditional Accreditation also results when an organization fails to meet requirements for the timely submission of data and information to The Joint Commission; or survey findings demonstrate systemic patterns, trends or repeat findings from previous surveys; or there is credible evidence indicating that possible fraud or abuse has occurred at a health care organization.
Preliminary Denial of Accreditation results when a health care organization fails to resolve the requirements of a Conditional Accreditation status or was in substantial noncompliance with applicable Joint Commission standards. Preliminary Denial of Accreditation also results when there is evidence of an immediate threat to health or safety for patients or the public within the health care organization or there is credible evidence indicating that the organization submitted falsified documents or misrepresented information in seeking accreditation.
Denial of Accreditation results when a health care organization does not permit the performance of any survey by The Joint Commission. Denial of Accreditation also results when the organization fails to meet requirements for the timely submission of data and information to The Joint Commission, or resolve a Conditional Accreditation status prior to withdrawing from the accreditation process, or submit payment for survey fees or annual fees.
Preliminary Accreditation results when the health care organization demonstrates compliance with selected standards used in the first survey conducted under the Early Survey Policy.
More information about accreditation decisions, policies and procedures can be found in The Joint Commission’s accreditation manuals.