Approved: 2016 Accreditation and Certification Decision Rules
The Joint Commission’s Board of Commissioners recently approved the 2016 accreditation and certification decision rules for all accreditation and certification programs. These decision rules are effective for surveys and reviews beginning January 1, 2016, and are shown in the boxes on pages 7–12 for accreditation programs and pages 12–13 for certification programs. New text is underlined and deleted text is shown in strikethrough.
Specific changes to the accreditation and certification decision rules include the following:
l Separated decision rules for organizations seeking initial accreditation from decision rules for organizations seeking reaccreditation
l Revised Contingent Accreditation CONT02 and Accreditation with Follow-up Survey AFS03 so that organizations now have two opportunities to come into compliance with the standards
l Revised AFS08 so that it addresses instances in which organizations fail their Medicare follow-up survey
l Added Medicare Survey category and decision rule Condition-Level Deficiency CLD01 to clarify that a Medicare follow-up survey will occur if organizations have any Condition-level deficiencies
l Added new Evidence of Standards Compliance ESC02 and Measure of Success MOS02 to clarify that failure to successfully address all Requirements for
Improvement (RFIs) may require the second submission of an ESC or MOS, respectively
l Added Not Certified NC03 to address failure to submit payment for review fees or annual fees
The November E-dition® release—as well as the hard copy fall 2015 publica- tions of the comprehensive accreditation manuals and certification manuals—will include these new accreditation and certi- fication decision rules. p
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Official Publication of Joint Commission Requirements
ApplicAble to All AccreditAtion progrAms Unless stAted otherwise
Decision Rules for Organizations Seeking Reac- creditation
Effective January 1, 2016
Denial of Accreditation
Denial of Accreditation will be recommended when one or more of the following conditions are met:
DA01 The [organization] does not permit the perfor- mance of any survey by The Joint Commission. (APR.02.01.01, EP 1)
DA02 The [organization] has failed to resolve an Accreditation with Follow-up Survey or Contingent Accreditation status prior to withdrawing from the accreditation process.
DA03 The [organization] has failed to submit payment for survey fees or annual fees.
DA04 The [organization] has repeatedly failed to submit an ESC and/or MOS.
Preliminary Denial of Accreditation
Preliminary Denial of Accreditation will be recommended when one or more of the following conditions are met:
PDA01 An Immediate Threat to Health or Safety exists for [patients], staff, or the public within the [organiza- tion]. (APR.09.04.01, EP 1)
PDA02 The [organization’s] [patients] have been placed at risk for a serious adverse outcome(s) due to significant and pervasive patterns, trends, and/or repeat findings.
PDA03 The [organization’s] [patients] have been placed at risk for a serious adverse outcome because either an individual who does not possess a license, registration, or certification is providing or
has provided health care services in the [organiza- tion] that would, under applicable law or regulation, require such a license, registration, or certification; or an individual is practicing outside the scope of his or her license, registration, or certification.
The following cross-reference applies to critical
access hospitals and hospitals only: (HR.01.02.07, EPs 1 and 2; MS.06.01.05, EP 1)
The following cross-reference applies to ambulatory care and office-based surgery practices only:
(HR.01.02.07, EPs 1 and 2; HR.02.01.03, EP 4)
The following cross-reference applies to nursing care centers only:
(HR.01.02.07, EPs 1 and 2; HR.02.01.04, EP 15)
The following cross-reference applies to home care and laboratories only:
(HR.01.02.07, EPs 1 and 2)
The following cross-reference applies to behavioral health care only:
(HRM.01.01.03, EPs 1 and 2)
PDA04 The [organization] does not possess a license, certificate, and/ or permit, as or when required by applicable law and regulation, to provide the health care services for which the [organization] is seeking accreditation. (LD.04.01.01, EP 1)
PDA05 The Joint Commission is reasonably persuaded that the [organization] submitted falsified docu- ments or misrepresented information in seeking to achieve or retain accreditation. Information provided by [an organization] and used by The Joint Commission for accreditation purposes must
be accurate and truthful and may be received in the following ways:
l Provided verbally, in writing, or electronically
l Obtained through direct observation by, or in an interview with, or via any other type of communi- cation with a Joint Commission employee
l Derived from documents supplied by the [organi- zation] to The Joint Commission including, but not limited to, its application for accreditation
or its comprehensive systematic analysis in response to a sentinel event
l Submitted electronically to The Joint Commis- sion including, but not limited to, data or docu- ments provided as part of [the ICM process or] the electronic application process
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If accreditation is denied following implementation of this rule, the [organization] shall be prohibited from participating in the accreditation process for a period of one year unless the president of The Joint
Commission, for good cause, waives all or a portion of this waiting period. (APR.01.02.01, EP 1)
PDA06 The [organization] with a decision of Contingent Accreditation has failed to clear noncompliant standards as a result of the follow-up survey.
Applicable to laboratories only:
PDA07 The laboratory has failed to comply with a cease testing order issued by The Joint Commission, one of its cooperative partners, or a regulatory agency.
Applicable to laboratories only:
PDA08 The organization’s laboratory personnel have referred proficiency testing samples to another laboratory for analysis or participated in inter- laboratory communication regarding proficiency testing results before the results have been reported to the program provider. (QSA.01.04.01, EPs 1 and 2)
Contingent Accreditation
Contingent Accreditation will be recommended when one or more of the following conditions are met:
CONT01 If the Immediate Threat to Health or Safety abate- ment survey through direct observation or other determining method has demonstrated that the [organization] has implemented sufficient corrective action to warrant removal of the Immediate Threat, the Accreditation Committee may change the decision to Contingent.
CONT02 The [organization] with a decision of Accredita- tion with Follow-up Survey has failed to resolve all requirements after two opportunities.
CONT03 There is some evidence that the [organization] may have engaged in possible fraud or abuse. (LD.04.02.03, EP 3)
Accreditation with Follow-up Survey
Note: The Accreditation with Follow-up Survey could occur within 30 days or up to six months after the decision is rendered.
Accreditation with Follow-up Survey will be recommended when one or more of the following conditions are met:
AFS01 The [organization] demonstrates systemic patterns, trends, and repeat findings primarily with direct
impact and/or risk-related standards.
AFS02 The [organization] demonstrates systemic patterns, trends, and repeat findings with indirect impact standards.
AFS03 The [organization] fails to successfully address all RFIs in an ESC or MOS after two opportunities.
AFS04 At least two on-site ESC demonstrate the need for continued monitoring to assess whether the [orga- nization] sustains improvements.
AFS05 The [organization], which has failed to resolve one or more of its original RFIs, may be scheduled for a second Accreditation with Follow-up Survey.
Applicable to all programs except for office-based surgery practices:
AFS06 The [organization] fails to participate in Intracycle Monitoring requirements.
Applicable to laboratories only:
AFS07 The laboratory fails to submit a written plan of action for unsuccessful proficiency testing after two requests from The Joint Commission.
Applicable to ambulatory care, critical access hospitals, hospi- tals, and home care only:
AFS08 The [organization] fails its Medicare follow-up survey as a result of has one or more Conditions of Participation [for ambulatory care: Conditions for Coverage] scored as a Condition-level deficiency.
Note: This rule applies only to [organizations] that [elect to] use accreditation for deemed status pur- poses and that are already Medicare certified.
AFS09 An individual who does not possess a license, registration, or certification is providing or has pro- vided health care services in the [organization] that would, under applicable law or regulation, require such a license, registration, or certification; or an individual is practicing outside the scope of his or her license, registration, or certification.
The following cross-reference applies to critical access hospitals and hospitals only:
(HR.01.02.07, EPs 1 and 2; MS.06.01.05, EP 1)
The following cross-reference applies to ambulatory care and office-based surgery practices only:
(HR.01.02.07, EPs 1 and 2; HR.02.01.03, EP 4)
The following cross-reference applies to nursing
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care centers only:
(HR.01.02.07, EPs 1 and 2; HR.02.01.04, EP 15)
The following cross-reference applies to home care and laboratories only:
(HR.01.02.07, EPs 1 and 2)
The following cross-reference applies to behavioral health care only:
(HRM.01.01.03, EPs 1 and 2)
Note: Except as provided under rule PDA03.
Applicable to all except laboratories:
AFS10 The [organization] has failed to implement or make sufficient progress toward the Plan for Improvement (PFI) described in a Statement of Conditions, which that was previously accepted by The Joint Com- mission; or has failed to develop and implement the interim life safety measures (ILSM) policy and its criteria associated with evaluation and compensa- tion for increased safety.
The following cross-reference applies to critical access hospitals, hospitals, home care, nursing care centers, and office-based surgery practices only:
(LS.01.01.01, EP 3; LS.01.02.01, EP 3)
The following cross-reference applies to ambulatory care and behavioral health care only:
(LS.01.01.01, EP 3)
Note applies to home care only:
Note: This rule applies to hospice inpatient facilities only.
Applicable to ambulatory care, critical access hospitals, hospi- tals, and home care only:
A Medicare survey will be performed when the following condition is met:
CLD01 The [organization] has one or more Conditions of Participation [for ambulatory care: Conditions for Coverage] scored as a Condition-level deficiency.
Note: This rule applies only to [organizations] that use accreditation for deemed status purposes. [Organizations] currently not Medicare certified that receive one or more Condition-level deficiencies as a result of a survey event will be required to have a new, second initial unannounced Medicare survey
to demonstrate full compliance with all Medicare requirements. [Organizations] currently Medicare certified that receive one or more Condition-level deficiencies as a result of a survey event will be required to have an unannounced Medicare Defi- ciency follow-up survey to demonstrate full compli- ance with Medicare requirements.
Applicable to ambulatory care, critical access hospitals, hospi- tals, laboratories, and office-based surgery practices only:
One-Month Survey
A one-month survey will be performed when the following condition is met:
FOC01 A full laboratory survey will be conducted when [an organization] providing laboratory services cannot demonstrate to The Joint Commission that its labo- ratory accreditation decision is in good standing with a Joint Commission–recognized accreditor or the accreditation is more than 24 months old.
Applicable to laboratories only:
Retrospective Cytology Survey
A retrospective cytology survey will be scheduled within 45 days when the following condition is met:
FOC02 A retrospective cytology survey will be conducted if, during a full laboratory survey, a laboratory provid- ing cytology services is observed to have quality issues in this specialty. This will require a special survey that includes, but is not limited to, a review of slides for diagnostic discrepancies, evaluation
of policies and procedures, and verification of staff workload.
Applicable to laboratories only:
Proficiency Testing Monitoring Survey
A proficiency testing monitoring survey will be scheduled when the following condition is met:
PTM01 The laboratory has either initial or subsequent unsuccessful proficiency test performance and a determination is made that an on-site evaluation is required to assess either the plan of action or the plan for reinstatement when applicable, following cessation of testing (voluntary or involuntary).
Evidence of Standards Compliance (ESC)
An ESC will be required when one or more of the following conditions are is met:
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ESC01 [An organization] has one or more noncompliant standards at the time of a survey event.
ESC02 [An organization] that fails to successfully address all RFIs in an ESC may be required to submit a second ESC.
On-site ESC Survey
An on-site ESC survey will be scheduled when the following condition is met:
ESC0203 An on-site evaluation may be scheduled to validate compliance with the relevant standards in a written ESC.
Measure of Success (MOS)
An MOS for all applicable EP corrections will be required when either of the following conditions is met:
MOS01 The [organization] has submitted a successful ESC for an EP that requires an MOS submission.
MOS02 [An organization] that fails to successfully address all RFIs in an MOS may be required to submit a second MOS.
Preliminary Accreditation
Preliminary Accreditation will be recommended when the following condition is met:
PA01 The [organization] has demonstrated compliance with the selected standards used in the first survey conducted under the Early Survey Policy.
Accredited
Accreditation will be recommended when one or more of the following conditions are met:
A01 The [organization] is in compliance with all stan- dards at the time of the on-site survey or has successfully addressed all RFIs in its first ESC submission and does not meet any rules for other accreditation decisions.
A02 The [organization], as a result of an on-site follow- up survey, is compliant with the original survey RFIs.
Note: Should additional RFIs be identified, appro- priate decision rules apply.
Applicable to ambulatory care, behavioral health care, critical access hospitals, hospitals, and nursing care centers only:
[Add-On] Certification
The following rules will be used for Joint Commission–accred- ited [organizations] that choose to achieve add-on certifica-
tion for [Primary Care Medical Home Certification; Behavioral Health Home Certification; Post–Acute Care Certification; Memory Care Certification]:
A Joint Commission–accredited [organization] will be certified for the [add-on certification] program if it is in compliance with all [add-on certification] standards at the time of the on-site survey.
A Joint Commission–accredited [organization] will be certified for the [add-on certification] program if it has successfully addressed all [add-on certification] RFIs in its ESC submission.
A Joint Commission–accredited [organization] will not be certified for the [add-on certification] program if it does not meet all Joint Commission
standards for [add-on certification] either at the time of its on-site survey or following submission of an ESC.
Decision Rules for Organizations Seeking Initial Accreditation
Denial of Accreditation
Denial of Accreditation will be recommended when one or more of the following conditions are met:
DA01 The [organization] does not permit the perfor- mance of any survey by The Joint Commission. (APR.02.01.01, EP 1)
DA03 The [organization] has failed to submit payment for survey fees or annual fees.
DA04 The [organization] has repeatedly failed to submit an ESC and/or MOS.
DA05 [An organization] undergoing its first Joint Commis- sion survey has placed patients at risk for a serious adverse outcome(s) due to significant and perva- sive patterns and trends in survey findings.
DA06 An Immediate Threat to Health or Safety exists for [patients], staff, or the public within the [organiza- tion] undergoing its first Joint Commission survey. (APR.09.04.01, EP 1)
DA07 The Joint Commission is reasonably persuaded that the [organization] submitted falsified docu- ments or misrepresented information in seeking to achieve or retain accreditation. Information provided by [an organization] and used by The Joint Commission for accreditation purposes must
be accurate and truthful and may be received in the following ways:
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l Provided verbally, in writing, or electronically
l Obtained through direct observation by, or in an interview with, or via any other type of communi- cation with a Joint Commission employee
l Derived from documents supplied by the [organi- zation] to The Joint Commission including, but not limited to, its application for accreditation
or its comprehensive systematic analysis in response to a sentinel event
l Submitted electronically to The Joint Commis- sion including, but not limited to, data or docu- ments provided as part of [the ICM process or] the electronic application process
If accreditation is denied following implementation of this rule, the [organization] shall be prohibited from participating in the accreditation process for a period of one year unless the president of The Joint Commission, for good cause, waives all or a portion of this waiting period. (APR.01.02.01, EP 1)
DA08 The [organization] undergoing its first Joint Com- mission survey fails to successfully address all RFIs in an ESC or MOS after two opportunities.
Applicable to ambulatory care, critical access hospitals, hospi- tals, and home care only:
DA09 The [organization] undergoing its first Joint Com- mission survey fails its Medicare follow-up survey as a result of a one or more Conditions of Participa- tion [for ambulatory care: Conditions for Coverage] scored as a Condition-level deficiency.
Applicable to ambulatory care, critical access hospitals, hospi- tals, and home care only:
Medicare Survey
A Medicare survey will be performed when the following condition is met:
CLD01 The [organization] has one or more Conditions of Participation [for ambulatory care: Conditions for Coverage] scored as a Condition-level deficiency.
Note: This rule applies only to [organizations] that use accreditation for deemed status purposes. [Organizations] currently not Medicare certified that receive one or more Condition-level deficiencies as a result of a survey event will be required to have a new, second initial unannounced Medicare survey
to demonstrate full compliance with all Medicare requirements. [Organizations] currently Medicare certified that receive one or more Condition-level deficiencies as a result of a survey event will be required to have an unannounced Medicare Defi- ciency follow-up survey to demonstrate full compli- ance with Medicare requirements.
Applicable to ambulatory care, critical access hospitals, hospi- tals, laboratories, and office-based surgery practices only:
One-Month Survey
A one-month survey will be performed when the following condition is met:
FOC01 A full laboratory survey will be conducted when [an organization] providing laboratory services cannot demonstrate to The Joint Commission that its labo- ratory accreditation decision is in good standing with a Joint Commission–recognized accreditor or the accreditation is more than 24 months old.
Applicable to laboratories only:
Retrospective Cytology Survey and Proficiency Testing Monitoring Survey (see category text on page 9)
Evidence of Standards Compliance (ESC)
An ESC will be required when one or more of the following conditions are met:
ESC01 [An organization] has one or more noncompliant standards at the time of a survey event.
ESC02 [An organization] that fails to successfully address all RFIs in an ESC may be required to submit a second ESC.
ESC03 An on-site evaluation may be scheduled to validate compliance with the relevant standards in a written ESC.
Measure of Success (MOS)
An MOS for all applicable EP corrections will be required when either of the following conditions is met:
MOS01 The [organization] has submitted a successful ESC for an EP that requires an MOS submission.
MOS02 [An organization] that fails to successfully address all RFIs in an MOS may be required to submit a second MOS.
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Preliminary Accreditation
Preliminary Accreditation will be recommended when the fol- lowing condition is met:
PA01 The [organization] has demonstrated compliance with the selected standards used in the first survey conducted under the Early Survey Policy.
Accredited
Accreditation will be recommended when one or more of the following conditions are met:
A01 The [organization] is in compliance with all standards at the time of the on-site survey or has successfully addressed all RFIs in its first ESC submission and does not meet any rules for other accreditation decisions.
A02 The [organization], as a result of an on-site follow- up survey, is compliant with the original survey RFIs.
Note: Should additional RFIs be identified, appro- priate decision rules apply.
Applicable to ambulatory care, behavioral health care, critical access hospitals, hospitals, and nursing care centers only:
[Add-On] Certification
The following rules will be used for Joint Commission–accred- ited [organizations] that choose to achieve add-on certifica- tion for [Primary Care Medical Home Certification; Behavioral Health Home Certification; Post-Acute Care Certification; Memory Care Certification]:
A Joint Commission–accredited [organization] will be certified for the [add-on certification] program if it is in compliance with all [add-on certification] standards at the time of the on-site survey.
A Joint Commission–accredited [organization] will be certified for the [add-on certification] program if it has successfully addressed all [add-on certification] RFIs in its ESC submission.
A Joint Commission–accredited [organization] will not be certified for the [add-on certification] program if it does not meet all Joint Commission
standards for [add-on certification] either at the time of its on-site survey or following submission of an ESC.
Official Publication of Joint Commission Requirements
ApplicAble to All stAnd-Alone certificAtion progrAms
Effective January 1, 2016
Not Certified
A decision of Not Certified will be recommended when one or more of the following conditions are met:
NC01 The [staffing firm/program] does not permit the per- formance of any review by The Joint Commission. (CPR 3, EP 1)
NC02 The [staffing firm/program] has failed to meet Joint Commission requirements after two opportunities.
NC03 The [staffing firm/program] has failed to submit payment for review fees or annual fees.
Preliminarily Not Certified
A decision of Preliminarily Not Certified will be recommended when the following condition is met:
PNC01 The [program/staffing firm] has failed to success- fully address all RFIs in an ESC or MOS after two opportunities.
Evidence of Standards Compliance (ESC)
An ESC will be required when one or more of the following conditions are is met:
ESC01 A [program/staffing firm] has one or more standards scored not compliant at the time of a review event.
ESC02 A [program/staffing firm] that fails to successfully address all RFIs in an ESC may be required to submit a second ESC.
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On-site ESC Review
An on-site ESC review will be scheduled when the following
Certified
submit a second MOS.
condition is met:
ESC0203 An on-site evaluation may be scheduled to validate compliance with the relevant standards in a written ESC.
Measure of Success (MOS)
An MOS for all applicable EP corrections will be required when either of the following conditions is met:
MOS01 The [staffing firm/program] has submitted a successful ESC for an EP that requires an MOS submission.
MOS02 A [staffing firm/program] that fails to successfully address all RFIs in an MOS may be required to
A decision of Certified will be recommended when one or more of the following conditions are met:
CT01 The [program/staffing firm] is in compliance with all standards at the time of the on-site review or has successfully addressed all RFIs.
CT02 The [program/staffing firm], as a result of an on-site ESC follow-up review, is compliant with the original review RFIs.
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