Joint Commission accreditation is not only a mark of excellence but also a requirement for deemed providers receiving CMS funding and demonstrating a commitment to patient safety. However, the accreditation process can be rigorous, and a preliminary denial of accreditation decision from the Joint Commission can have serious consequences. 

There has been a marked increase in the number of clients reaching out to us due to a preliminary denial of accreditation (PDA) decision from the Joint Commission.  Both Hospital, Behavioral Health  and Home Care providers are reporting an increase in survey rigor and PDA decisions.

A Preliminary Denial of Accreditation Decision Requires Immediate and Decisive Action

Providers must take quick and decisive action to address the non-compliant standards driving the PDA decision. These steps can help organizations navigate the post-survey process and prevent future issues.

Start with a debrief of leaders to identify likely findings stemming from the Exit Conference. The organization’s leaders should review the identified areas of deficiency and establish the next steps for correction.  A member of the senior leadership team should be assigned to take the lead responsibility for corrective action on each likely finding. Confirm findings when the final Joint Commission Report is posted to your extranet site.

Create an Executive Summary of findings as a formal record of the state of the organization’s current accreditation & regulatory status.  Create a timeline of subsequent corrective action deadlines and anticipated events such as follow-up surveys or agency communication.  Immediately notify your board, Medical Executive Committee or Medical Staff officers of the Executive Summary and timeline.

Notify and secure participation of legal counsel and an accreditation & regulatory compliance consultant.  The legal counsel and compliance consultant will help support the hospital in addressing any legal concerns related to the survey report and the development of a comprehensive plan to address the deficiencies.

Root Cause Analysis and Plan of Action

A preliminary denial of accreditation decision requires you to identify root cause(s). It is critical to understand why deficiencies occurred, and a thorough investigation may help detect specific areas or departments that need attention.  After the root causes have been identified, the development of plans of action to correct and prevent any further deficiencies from arising is vital. Keep track of actions taken as well as the dates these actions are taken as this information will be required for your evidence of standards compliance and any follow-up events from the Joint Commission.

Initiate Interventions

Modify the organization’s policies and processes as necessary. Be sure to keep track of versions prior to and after the survey and highlight specific sections that have undergone revision. Educate and validate competency on required changes in policies and processes. 

Monitor the Results

Develop a monitoring plan that is sensitive enough to allow confirmation of sustainable corrective action.  Monitor compliance and report results to senior leadership, the Board, and medical staff leaders. Re-educate and reinforce new policies and procedures to improve compliance.

Prepare Evidence of Compliance

Assemble an evidence binder and prepare staff for the follow-up survey.  Conduct mock follow-up surveys to prepare staff for all anticipated Joint Commission survey activities.  Focus on the corrective actions taken to bring non-compliant standards into compliance.  Be aware, all Joint Commission standards & CMS CoPs are eligible for survey so new findings can occur including finding additional Standards & CoPs out of compliance.

Joint Commission Accreditation Resources

• Standards Interpretation FAQs
• Standard Interpretation Question
• Heads Up Reports 
• Upcoming Webinars
• Webinar Replays
• Perspective Magazine (JC Connect)
• Editors’ Exclusives
• Case Examples
• Person to Person
• R3 Reports
• Quick Safety
• Joint Commission Online
• Sentinel Event Alert
• EC News
• Office of Quality and Patient Safety
• Suicide Prevention Portal
• Other

Barrins and Associates Consultation

Barrins & Associates has an expert team available to assist organizations with any Joint Commission adverse decision response such as Preliminary Denial of Accreditation (PDA), Condition Level Deficiency Survey (CLD), CMS Systems Improvement Agreement (SIA), Medicare Termination, Immediate Jeopardy (IJ) or Immediate Threat to Health & Safety (ITHS), Accreditation with Follow-Up Survey (AFS) and Complaint Survey.  We assist with clarifying findings, developing and implementing plans of correction, abatement survey preparation, Review Hearing Panel preparation, 5-day notice of appeal letters, and additional actions to mitigate adverse decisions.  We continue to be your partner in achieving and sustaining Joint Commission Accreditation and regulatory compliance.