Your Joint Commission survey ended 10 days ago. TJC just posted your final report. The decision is Preliminary Denial of Accreditation (PDA.) Not what you were hoping for.

So, what exactly does PDA mean? And, equally important, what should you do next?

The good news: There’s definitely a path back to full accreditation after a PDA. We’ve helped many organizations do just that.

The challenge is the timelines are tight. And, the requirements are intense. So, let’s dig into the details.

Preliminary Denial of Accreditation: Definition

TJC has a set of Accreditation Decision Rules for reaccreditation surveys. A PDA decision, by definition, results when surveyors identify one of the following situations:

• An Immediate Threat to health or safety to patients, staff, or the public (PDA01)
• Risk of serious adverse outcome due to significant and pervasive patterns, trends, and/or repeat findings (PDA02)
• Risk of serious adverse outcome due to staff lacking a required license/registration/ certification or practicing out of their scope (PDA03)
• Organization does not possess a legally required license for its services (PDA04)
• Evidence of submission of falsified documents or misrepresented information (PDA05)
• Failure to resolve the requirements of an Accreditation with Follow-up Survey (PDA06)
• For deemed status hospitals: Failing a second Medicare Deficiency Survey (PDA09)
• Evidence of organization engaging in possible fraud or abuse (PDA10)

PDA decisions can occur in both the Hospital Accreditation Program and the Behavioral Health Care & Human Services Accreditation Program. The most common type of PDA decision we see is PDA02: Patients Placed at Risk for Serious Adverse Outcomes Due to Significant and Pervasive Patterns, Trends, and/or Repeat Findings.

PDA Timelines

TJC has specific requirements and timelines for PDA decisions:

• Final survey report posted: within 10 business days of completion of the survey
• Option to clarify inaccurate findings: within 10 business days of posting of final report
• Plan of Correction (POC) due to TJC: within 10 business days of posting of final report. The POC must address ALL Requirements for Improvement on the survey report.
• For hospitals with CMS deemed status: Unannounced Medicare Deficiency Survey within 45 calendar days from last day of survey
• Unannounced PDA Validation Survey to review POC implementation: within 60 calendar days of posting of final report
• If the Validation Survey is successful:
  • TJC revises its Quality Check website from PDA to a Time Limited PDA and an Accreditation with Follow-up Survey decision.
  • TJC conducts the Follow-up Survey within four months.
  • In addition, the organization must participate in the Intracycle Monitoring Process.
  • Lastly, TJC will conduct the next triennial survey within 18 – 20 months.
• If the Validation Survey is unsuccessful:
  • PDA status continues; organization has five business days to appeal to TJC Review Hearing Panel.
  • If organization doesn’t appeal or the appeal is unsuccessful, the decision is Denial of Accreditation.

PDA Strategies

Clarifications

First, determine if you’ll clarify any findings on your survey report. You should only do that for findings  that are inaccurate.

It’s true that TJC approves fewer and fewer clarifications these days. However, it’s always worth a try.

Also, its critically important to explicitly follow the TJC Clarification instructions. Go onto your TJC Connect site and review those – including the examples they supply. The closer you follow those, the better your chance of success.

Internal Action Plan

It’s critical to create an internal Action Plan as soon as your survey ends. You’ll have the Preliminary Report in hand on the final day of survey. Get started based on that report.

Don’t wait for the posting of your final report to begin developing your Action Plan. Typically, there are few (if any) changes from the Preliminary Report. Even if there are changes, you can adjust your Action Plan to address those.

Moreover, make sure your Action Plan is well structured. Your Action Plan should specifically address both the surveyor’s finding and the requirements of the standard. It should also have assignments for responsible parties, deliverables, and due dates.

Condition Level Deficiencies

If you’re a deemed status hospital and have Condition Level Deficiencies on your report, those should take top priority in your Action Plan. TJC will review only those Condition Level Deficiencies on the 45 Day Medicare Deficiency Survey. Remember, that’s 45 calendar days from your last day of survey.

Evidence Binders

We highly recommend you develop Evidence Binders for surveyors to review when they return. First, organize them with tabs for each finding on your report.

Next, describe your corrective actions for each survey finding. Last, attach any related documents. For example, revised policies, forms, meeting minutes, trainings, etc.

In this day of high tech options, Evidence Binders may seem old fashioned. However, they can be a valuable tool. Surveyors really appreciate them. Especially when they’re pressed for time on a one day Medicare Deficiency Survey.

Well-developed evidence binders also set the stage for your return surveys. They demonstrate your thorough, organized approach to correcting your deficiencies. Then, the surveyor can see those in action during their tracers.

Staff Preparation

Be sure you devote sufficient time to preparing your staff for any follow-up surveys. They need to understand the corrective actions you’ve implemented.

Moreover, they need to know their role in those corrective actions and be prepared to demonstrate that to the surveyors. So, get your team aligned from top to bottom.

Life after Preliminary Denial of Accreditation

We’ve worked with several organizations to resolve their PDA decisions. It’s a complicated and intense process. But with the right leadership team, resolving a PDA can lead to lasting improvements to patient safety and patient care processes.

Barrins & Associates Consultation

Maybe you’re looking for Post Survey Support after an adverse decision like a PDA. Or, you need a Mock Survey. We provide both types of service to support your ongoing compliance and survey readiness.