Requiring documentation from surveyors makes the results of external reviews more reliable

• Specific information about accreditation decisions, policies and procedures can be found in The Joint Commission’s accreditation manuals.
• The following is an overview of accreditation and certification decisions.

Accreditation Decisions

Accreditation is awarded to a health care organization that is in compliance with all applicable standards at the time of the on-site  survey or has successfully addressed all Requirements for Improvement (RFIs) in an Evidence of Standards Compliance (ESC) submission within 60 days following the posting of the Accreditation Survey Findings Report and does not meet any other rules for other accreditation decisions.

Accreditation with Follow-up Survey results when a health care organization is in compliance with all standards, as determined by an acceptable ESC submission. A follow-up survey is required within six months to assess sustained compliance.

Limited Temporary Accreditation results when a health care organization is in satisfactory compliance with the limited set of standards and elements of performance (EPs) assessed in the first of the two surveys conducted under the Early Survey Policy.

Preliminary Denial of Accreditation is recommended when there is justification to deny accreditation to a health care organization as evidenced by one or more of the following: an immediate threat to health or safety to patients or the public; submission of falsified documents or misrepresented information; lack of a required license or similar issue at the time of survey; failure to resolve the requirements of an Accreditation with Follow-up Survey status; or significant noncompliance with Joint Commission standards. This decision is subject to review and appeal by the organization before the determination to deny accreditation.

Denial of Accreditation results when a health care organization has been denied accreditation. All review and appeal opportunities have been exhausted. For an organization undergoing an initial survey, the organization has failed to demonstrate compliance with all applicable Joint Commission standards.

Certification Decisions

Certified programs meet all the requirements for their particular program. They either received no RFI or successfully addressed any RFIs through an ESC submission involving either clarifications or evidence of corrections for the review findings.

Not Certified programs are those that: apply for certification and – recognizing during their on-site review that they would not meet the requirements – requested that the review be changed to an education visit; or, failed to meet the requirements and did not have their review converted to an education visit. Programs that fail to meet the requirements will have to address any RFIs and submit an acceptable ESC.

Note: Although the results of a certification program’s decision have no effect on an organization’s accreditation status, a potential Immediate Threat to Health or Safety situation discovered during a certification review may trigger a for-cause accreditation survey of the larger organization that could affect its accreditation status.

Learn More

• Standards and survey process
• SAFER Matrix™
• Public Information on Quality Check®

What form of documentation is acceptable by The Joint Commission, electronic or paper? How quickly must documentation be accessible during a survey?

Any examples are for illustrative purposes only.

The Joint Commission surveyors will accept evidence of standards compliance in either a paper format or an electronic format. In either case, the documentation must be organized or accessible in such a way as to allow for timely review. For example, electronic medical records,  environment of care records, emergency management and life safety documentation can be completed  by reviewing a computer screen or wall projection.

Please note:

• A person from the organization must be available and have knowledge on how to efficiently navigate the electronic format.
• If the documents are not in English then a translator should be available to interpret.

The timeliness of accessibility to required documentation is an evaluative determination. The surveyor will work collaboratively with your organizations to establish a time frame to submit requested documents.  If the organization demonstrates a consistent pattern where requested documents are not readily available, then a Leadership finding (LD.04.01.05) may be made in addition to the requirement for improvement (RFI) for the missing documentation.

The Accreditation Survey Activity Guide (SAG) for Health Care Organizations, available to organizations via their secure extranet site or our website, includes a list of the documents required to be available to the survey team. Organizations may find it helpful to conduct 'mock surveys' that include evaluating timely access and availability of these documents.

Medical Records
There is no prescribed, required or recommended format for medical records. At the time of survey, medical records are evaluated for content, based on the applicable accreditation Elements of Performance (EP), not format. Organizations operating in a hybrid environment (both paper and electronic) or are in the process of migrating to an Electronic Medical Record (EMR) platform should have a 'super-user' available to staff during the survey to assist in navigating the record to locate information requested by the surveyor.

Clarifications and Lack of Required Documentation During Survey
Findings resulting from  'lack of required documentation at the time of survey' are not eligible for the clarification process. When an organization does not have required documentation available at the time of survey, the organization can expect that the surveyor will give the organization a reasonable amount of time to produce missing documents.  Following the survey, the organization will need to provide Evidence of Standards Compliance (ESC) that the required documentation has been addressed through corrective actions.

Manual: Home Care

Chapter: Leadership LD

First published date: April 11, 2016 This Standards FAQ was first published on this date.

This page was last updated on October 19, 2021