Accreditation Decisions
Accreditation decisions are based on the criticality of issues related to patient care and safety. At the end of the on-site survey, the Joint Commission survey team presents a preliminary Summary of Survey Findings Report. This report does not provide any scores or final accreditation decision. The Joint Commission will review the survey findings and the health car organization’s Evidence of Standards Compliance submission. It will then render an accreditation decision.
Beginning January 1, 2010, the following are possible accreditation decisions.
From the Joint Commission Website, “Facts About Accreditation Decisions for 2010” www.jointcommission.org/AboutUs/Fact_Sheets/10_acc_decisions.htm
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.
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.
Preliminary Accreditation results when the health care organization demonstrates compliance with selected standards used in the first survey conducted under the Early Survey Policy.