Your accreditation survey is over! You are tired but relieved, and now it is time to respond to the deficiencies found in your organization. What do you do next?
Hopefully, you did not receive any Immediate Threat to Health and Safety (ITHS) citations. If you did, this is what you need to do. TJC defines an ITHS as “a threat that represents immediate risk and may have serious adverse effects on the health or safety of the patient, resident, or individual served.” This will result in a Preliminary Denial of Accreditation decision based on the threat. Your organization's CEO will be notified, and TJC will provide written notification to CMS within two business days if you are a deemed status organization. Additional information concerning the threat will be forwarded to CMS within ten business days.
After notification of the Preliminary Denial of Accreditation decision, an organization has up to 72 hours to do the following:
- Eliminate the Immediate Threat to Health or Safety situation entirely.
- If the situation is such that it will take the organization more time to eliminate it, then the organization must implement emergency interventions to abate the risk to patients within 72 hours. If the situation is not eliminated within 72 hours, the organization will have a maximum of twenty-three calendar days to do so.
The Joint Commission will remove the need for a 23-day abatement survey for any organization that demonstrates that it took immediate action to remedy the situation entirely and adopted necessary system changes to prevent a future recurrence of the problem prior to the conclusion of the survey event during which the immediate threat situation was identified.
Upon resolution of an Immediate Threat to Health or Safety situation, if the organization does not meet any other Preliminary Denial of Accreditation decision rules, the organization’s accreditation status may change from Preliminary Denial of Accreditation to another accreditation decision, such as an Accreditation with Follow-up Survey, which shall remain as such until an accreditation follow-up survey is conducted to assess the organization’s sustained implementation of appropriate corrective actions.
The TJC accreditation decisions that an organization could get are as follows:
- Accredited-Compliance with all applicable requirements at the time of the survey was established or the organization has addressed all requirements for improvement (RFI) in the evidence of standard compliance (ESC) within sixty calendar days following the posting of the Final Accreditation Report and does not meet any other rules for other accreditation decisions.
- Accreditation with Follow-up Survey -Compliance with all standards has been established as determined by an acceptable ESC submission. A follow-up survey is required to assess sustainment of compliance.
- Preliminary Denial of Accreditation - There is justification to deny accreditation to the organization, for example:
- An Immediate Threat to Health or Safety to patients, staff, or visitors, and/or
- Falsified documents or misrepresented information was provided, and/or
- Lack of a required license or similar issue at the time of the survey and/or
- Requirements of Accreditation with Follow-up Survey have not been resolved and/or
- Significant noncompliance with Joint Commission standards.
A decision of Preliminary Denial of Accreditation may be subject to review and appeal, by the organization, prior to the determination to deny accreditation.
- Denial of Accreditation The organization has been denied accreditation. The organization has exhausted all available review and appeal opportunities, or voluntarily did not pursue review or appeal.
Clarifying Requirements for Improvement
Every non-compliant standard or element of performance found during survey will trigger a Requirement for Improvement. Organizations have two options at this point: (1) immediately begin correcting the deficiency and developing its evidence of standards compliance or (2) utilize the 10-day clarification process to clarify the accuracy of the Requirement for Improvement. Keep in mind, that findings that result in an Immediate Threat to Health or Safety finding cannot be clarified after survey.
Evidence of Standards Compliance
The organization should immediately begin the work of reviewing and modifying the processes associated with all areas identified as Requirements for Improvement, even before the final report is received unless you are seeking clarification. Note that some modifications to the report may occur when undergoing the central office review process, but changes are typically minimal. This submission is in the form of an Evidence of Standards Compliance and is submitted online on the organizations TJC extranet site. When submitting your ESC’s, you need to include the following details:
- Modifications made to establish compliance to the Element of Performance (EP) level
- Detailed-Action(s), inclusive of the final date of those action(s), that the organization took to re-establish compliance with a requirement
- Identification by title only of the staff ultimately responsible for implementing the actions taken to establish compliance and for sustaining compliance
- The plan for sustaining compliance, inclusive of how the organization will monitor the process
When findings rise to a level of high-risk, there are two additional requirements to the Evidence of Standards Compliance submission: (1) identification of Leadership by title, typically at the Executive level, that are involved in the corrective action and sustaining compliance plan and (2) use of preventive analysis, also known as Failure Mode Effect Analysis to ensure that a deep understanding of the process and areas of breakdown are identified and addressed.
ESC Due Dates
An acceptable ESC report is due within sixty calendar days following the posting of the Final Accreditation Report on your extranet site. The required period for ESC submission will also be specified in the final report. Following the submission of an acceptable ESC, the organization receives an accreditation outcome decision. Note, that the organization’s accreditation decision is retroactive to the last day of the survey unless the organization is undergoing its first first Joint Commission survey. For organization’s undergoing initial surveys, the effective accreditation date is based upon the date on which an acceptable ESC was submitted when there were findings resulting in RFI’s. If there are no RFIs, the effective date is the last day of the survey.
Once your organization submits its Evidence of Standards Compliance documentation, the submission will be reviewed by the Central Office team at TJC. An ESC is considered acceptable when the organization has demonstrated resolution of all RFIs and a letter indicating your accreditation status will be posted to your extranet site. It is essential that your organization continues to monitor these areas of opportunity to ensure sustained compliance, as repeat findings add additional risk to the organization upon their next accreditation survey.
The Joint Commission Comprehensive Accreditation Manual, 2022
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