Preliminary Denial of Accreditation (PDA) decisions are still trending upward. More and more organizations are facing PDA’s; which could result in a full denial if swift action is not taken by the organization.
Below is a timeline of activity after Preliminary Denial of Accreditation is decided:
- Final survey report posted
- Clarification of any inaccurate findings due in 10 business days after final report posted
- If Clarification of findings are submitted, The JC central office can accept or reject the Clarification and post a revised final report
- Once Clarification is completed or waived, Plans of Correction for all findings are due 10 business days after final report posted (or revised final report if Clarification was submitted)
- If Immediate Threat was declared, unannounced abatement survey may be conducted within 23 calendar days after survey to validate risk was removed
- Medicare deficiency survey focused on all CMS Condition-level deficiencies may be conducted within 45 calendar days from the last day of survey
- Validation survey focused on implementation of all Plans of Correction conducted within two months (60 days) after final (revised) report was posted
- If validation survey successful, Accreditation with follow-up survey conducted to assess sustained compliance with all findings within four months (120 days)
- If validation survey unsuccessful, PDA status continues, and healthcare organization has five (5) days to request an appeal
- If healthcare organization does not appeal, Denial of Accreditation is the final decision
- If validation survey successful, next full survey will be conducted on original schedule (18 to 36 months – times variable)
- If next full survey results in repeat Preliminary Denial of Accreditation, the healthcare organization will receive Denial of Accreditation
Preliminary Denial of Accreditation is reported to the Centers for Medicare and Medicaid Services (CMS). CMS will validate survey findings either independently or in conjunction with a JC survey team. CMS will also validate all Conditional findings reported from a PDA decision. All organizations should have and/or develop a plan for a PDA Decision. This decision will result in increased scrutiny, result in at least 2 additional survey’s and may drive further regulatory actions.
If your organization is in need of assistance after a Preliminary Denial of Accreditation has been issued, please contact Courtemanche & Associates at: https://www.courtemanche-assocs.com/contact/