You’ve been notified by The Joint Commission that your healthcare organization’s survey resulted in Preliminary Denial of Accreditation. This was not an outcome anybody anticipated, as previous accreditation and CMS surveys were uneventful. What does this mean? How is this determined? And what steps need to be taken for successful and expedient resolution?
Let me explain the Preliminary Denial of Accreditation decision and offer strategies to navigate the multifaceted process.
Note: For organizations seeking their first, initial Joint Commission Accreditation, only two outcomes exist: Accredited or Denied. This article will not discuss initial Accreditation surveys but will focus on accreditation renewal surveys.
Navigating Preliminary Denial of Accreditation
During the Survey
First and foremost, throughout the survey, resolve any inaccuracies and issues with the surveyor(s) while they are still on-site in your healthcare organization. Utilize the time designated on the survey agenda for special issue resolution and always include the team leader. If you still believe your organization is compliant, but the surveyor disagrees and continues to score a Requirement for Improvement, request that the team leader schedule a conference call with TJC’s central office staff. The purpose of this conference call is for the healthcare organization, surveyor(s) and team leader, and Joint Commission central office staff to discuss the issue, collaborate, and immediately resolve any survey issues.
Now let’s fast forward to the end of the survey, when a preliminary survey report is posted by the team leader. During the survey exit conference, pay attention to any inaccuracies and ask questions. Look closely at where the surveyors placed their findings on TJC’s SAFER Matrix ™ as findings will not be moved after survey, but the survey team leader may correct or delete any inaccuracies while still on-site.
Following the Survey
Within two weeks, a final survey report is provided to the healthcare organization and a Preliminary Denial of Accreditation decision is communicated. As soon as the surveyors exit your organization, get started on drafting Clarifications and Plans of Correction. Submit a Clarification when you believe the organization was actually in compliance at the time of survey. Once your Clarification is submitted, Joint Commission central office staff will attempt to determine if there is sufficient documented evidence of compliance to accept your Clarification. I highly recommend submitting Clarification for any findings that exceed the requirements of the Standards and Conditions of Participation.
Concurrently, work as an interdisciplinary team on developing Plans of Correction. Submit any Clarification first, then follow with Plans of Correction, which are future focused. Once Plans of Correction are submitted, you essentially waive the ability to submit Clarification.
Preliminary Denial of Accreditation: Why and When
Now let me summarize the reasons why a Preliminary Denial of Accreditation (PDA) decision is determined for healthcare organizations seeking renewal of accreditation.
Preliminary Denial of Accreditation (PDA) most commonly results from the following events:
- Immediate Threat to Health or Safety declared (triggers an expedited PDA 01)
- Egregious, pervasive, and/or repeat findings throughout the healthcare organization (PDA 02)
- An individual lacked required license, registration, or certification or practiced out of scope (PDA 03)
- Hospital lacked required license, registration, or permit (PDA 04)
- Falsification of documents or misrepresentation of information (PDA 05)
- Failure to resolve all Requirements for Improvement after two Accreditation with follow-up surveys (PDA 06)
- Second failed Medicare Deficiency survey (PDA 09)
- Possible fraud or abuse (PDA 10)
- Failure to abate the risk identified during Immediate Threat (PDA 11)
Here is timeline of activity after Preliminary Denial of Accreditation is decided:
- Preliminary survey report posted at the end of survey
- Final survey report posted within two weeks of the end of survey
- Clarification of any inaccurate findings (optional) due in 10 business days after final report posted
- If Clarification of findings is submitted, TJC central office staff accept or reject the Clarification and post a revised final report
- Once Clarification is completed or waived, Plans of Correction for all findings due in 10 business days after final report posted (or revised final report if Clarification was submitted)
- If Immediate Threat was declared, unannounced abatement survey conducted within 23 calendar days after survey to validate risk to patients was removed
- Medicare deficiency survey focused on all CMS Condition-level deficiencies 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 after final report posted
- If validation survey successful, Accreditation with follow-up survey conducted to assess sustained compliance with all findings within four months
- If validation survey unsuccessful, PDA status continues, and healthcare organization has five 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 conducted within 18-33 months
- If next full survey results in repeat Preliminary Denial of Accreditation, the healthcare organization will receive Denial of Accreditation
Demystifying the Preliminary Denial of Accreditation Process
Navigating a Preliminary Denial of Accreditation decision can be mystifying. I’m available to remove the mystery and partner with you and your healthcare organization throughout the process. If there are challenges with team formation, rivalries among competing groups, or denial about the need to address identified issues, an outside consultant and facilitator with knowledge of the accreditation process and experience pulling leadership groups together may prove to be advantageous.
I encourage you to contact the Compass Clinical Consulting office at (513) 241.0142 or via email to set up a time to talk confidentially about your needs so we can help you submit your Clarification, remove risk to patients, develop Plans of Correction, and successfully resolve the Preliminary Denial of Accreditation decision.
About Lisa Prytula, MA, RN-BC
Lisa Prytula, MA, RN-BC, has joined Compass Clinical Consulting as Associate Managing Director. Lisa has more than 20 years of experience specializing in healthcare quality, accreditation and regulatory compliance, and performance improvement.
Previously the Director of Standards Interpretation at The Joint Commission, Lisa brings to Compass expert knowledge in the accreditation standards and Centers for Medicare and Medicaid Services Conditions of Participation. With this expertise, along with hospital leadership experience, project management skills, and a customer service focus, Lisa is positioned to provide both clinical and operational leadership and support to clients across all of Compass’s service lines.