The Joint Commission has approved the 2016 accreditation and certification decision rules for all accreditation and certification programs.
These decision rules are effective for surveys and reviews beginning Jan. 1, 2016.
The changes include:
-
separate decision rules for organizations seeking initial accreditation and organizations seeking reaccreditation;
-
revisions to “Contingent Accreditation” and “Accreditation with Follow-up Survey” designations so that organizations will have two opportunities to come into compliance with the standards;
-
a revision that addresses instances in which organizations fail their Medicare follow-up survey;
-
new Evidence of Standards Compliance (ESC) and Measures of Success (MOS) to clarify that failure to successfully address all Requirements for Improvement might require the second submission of an ESC or MOS.
New decision categories
The Joint Commission also added three new decision categories:
-
Medicare Survey;
-
Condition-Level Deficiency, to clarify that a Medicare follow-up survey will occur if organizations have any condition-level deficiencies;
-
Not Certified, to address failure to submit payment for review fees or annual fees.
Offices’ LS chapter cut
In other news, effective immediately, the Life Safety chapter is no longer applicable for office-based surgery practices accredited by The Joint Commission.
The removal of the Life Safety chapter aligns with revised eligibility criteria for office-based surgery practices that became effective Jan. 1, 2015.
The revised criteria limit office-based surgery practices to a business occupancy, which is an occupancy having three or fewer patients at the same time who are rendered incapable of self-preservation in an emergency or are undergoing general anesthesia. The Life Safety chapter applies to facilities classified as ambulatory health care occupancy, which means having at least four patients at the same time who are rendered incapable of self-preservation in an emergency or are undergoing general anesthesia.
