Certification is awarded after a review to a health care program or service that is in compliance with all standards at the time of the onsite review or has successfully addressed requirements for improvement in an Evidence of Standards Compliance (ESC) within 45 or 60 days following the posting of the Certification Review Finding Report. If the program or service does not meet these requirements for certification, it will receive one of the following decisions.
Provisional Certification results when a health care program or service fails to do one or more of the following: 1) Successfully address all requirements for improvement in an ESC within 45 or 60 days following the review or in a Measures of Success submission. 2) Meet all requirements for the timely submission of data and information to The Joint Commission within 31 days of the due date(s).*
Conditional Certification results when a health care program or service was previously in Preliminary Denial of Certification due to an Immediate Threat to Health or Safety situation; or the health care program or service failed to resolve the requirements of a Provisional Certification; or it was not in substantial compliance with the applicable standards, as usually evidenced by a single issue or multiple issues that pose a threat to the public health and safety that was present at the time of the review. The health care program or service must remedy identified problem areas through preparation and submission of ESC and subsequently undergo an onsite, follow-up review. In addition, a health care program or service may receive a Conditional Certification decision for failure to meet certain Joint Commission participation requirements, such as timely submission of data.*
Preliminary Denial of Certification results when there is justification to deny certification to the health care program or service as evidenced by an immediate Threat to Health or Safety situation; or the health care program; or service failed to resolve the requirements of a Conditional Certification; or was in significant noncompliance with Joint Commission standards. The decision is subject to appeal prior to the determination to deny certification; the appeal process may also result in a decision other than Denial of Certification.
Denial of Certification results when the health care program or service chooses not to appeal or the appeal of a Preliminary Denial of Certification decision is rejected; or a health care program or service does not permit the performance of any review by The Joint Commission; or the program or service fails to do one or more of the following: 1) Meet requirements for the timely submission of data and information to The Joint Commission within 91 days of the due date(s).* 2) Resolve a Conditional Certification status prior to withdrawing from the certification process. 3) Submit payment for review fees or annual fees.
* Data and information that is expected to be submitted on a timely basis to The Joint Commission include but are not limited to the certification contract, annual updates to the health care program or service’s application for certification, and annual intra-cycle evaluation.
More information about certification decisions, policies and procedures can be found in all of The Joint Commission’s certification manuals.
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