Recent changes have been made to simplify and streamline The Joint Commission’s post-survey process and decision rules. Now, an organization with a decision of Accredited with Follow-up Survey will receive notice of full accreditation once it has successfully submitted Evidence of Standards Compliance (ESC). However, a Follow-up Survey must be conducted within six months to confirm sustained compliance with the ESC.
The category of Contingent Accreditation has been eliminated. Now, there are only four possible decision categories for currently accredited organizations:
- Accredited with Follow-up Survey
- Preliminary Denial of Accreditation
- Denial of Accreditation
The category of Preliminary Denial of Accreditation has some new decision rules. All of the 2017 decision rules can be found on Joint Commission Connect™ under the “Important Updates” section. In addition to those categories already existing, organizations will receive a Preliminary Denial of Accreditation decision when:
- An organization with a decision of Accredited with Follow up Survey has failed to resolve all Requirements for Improvement after two opportunities to submit ESCs (PDA06)
- The organization has failed its second Medicare Deficiency Survey as a result of one or more Conditions of Participation (or Coverage for ASC scored as a Condition Level Deficiency) (PDA 09)
- The organization’s patients have been placed at risk for a serious adverse outcome, because there is some evidence that the organization may have engaged in possible fraud or abuse (PDA 10)
The post-survey process for organizations with a decision of Preliminary Denial of Accreditation (PDA 02) also has changed. A PDA 02 decision is made when an organization may have placed patients at risk for serious adverse outcomes because of patterns, trends and/or repeat findings. Instead of submitting ESC within 60 days, organizations with a PDA 02 decision are required to submit a Plan of Correction within 10 business days of the posting of the final report. A survey to validate the implementation of the Plan of Correction will occur within two months. If the validation survey does not confirm implementation of the Plan of Correction, the decision will remain PDA and the organization may seek an appeal.
For more information on this new process for PDA 02, see the “Important Updates” tab on your organization’s Joint Commission Connect™.
Finally, the governance structure of The Joint Commission has transitioned accreditation decision making from an Accreditation Committee to an executive team. Joint Commission executive leaders are now responsible for making accreditation decisions, taking into consideration the survey report, follow-up activities, staff recommendation, and any unusual or unique issues raised by the organization seeking accreditation. (Contact: firstname.lastname@example.org)