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Joint Commission changes preliminary denial of accreditation rules

Accreditation Connection, November 16, 2009

The Joint Commission has announced two changes to its Preliminary Denial of Accreditation (PDA) decision— the elimination of one rule and revision of another.

Rule PDA06, which addresses the need to have a license, certificate, or permit, has been altered.

Previously, if an organization was found to lack certain specific licenses, certificates, or permits at the time of survey, the organization would receive a PDA decision. This lack of license or permit often was the result of the organization being unaware such a permit was needed, and would result in immediately obtaining the permit (or, if the permit application is already in process, demonstrating during the survey that steps to apply for the permit have been taken).

Under this change, however, the organization lacking the license must now show an acceptable Evidence of Standard Compliance demonstrating that the organization has received the necessary license, certificate, or permit—until that time the organization receives an accreditation decision pending receipt of this documentation and receive a Requirement for Improvement (RFI).

In order to assure The Joint Commission that appropriate processes or policies are in place for obtaining this license or permit (and thus it will be renewed in the future in a timely manner), the RFI will remain in the survey report.

Additionally, the accreditation organization has completely eliminated rule PDA07, which was invoked after a healthcare organization received a Preliminary Denial decision on two consecutive full surveys.

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