Q&A: Immediate threat to health and safety

Q: What happens if something is deemed an immediate threat to health or safety?

A: Should a situation exist that triggers a determination of immediate threat to health or safety, an expedited decision of preliminary denial of accreditation (PDA) may be issued, and the organization has up to 72 hours to eliminate the threat. If more time is warranted, interim safety measures must be implemented; up to 23 days will be allowed for complete resolution of the issue.

Important note: Citations of immediate threat to health or safety cannot be “clarified”; the PDA decision is posted on the Quality Check section of The Joint Commission’s website.

Once the organization notifies The Joint Commission that it has resolved the immediate threat, The Joint Commission will conduct a follow-up on-site visit called an “abatement survey” to validate that action has been taken and that the threat has been corrected. Then, the PDA will be changed to a conditional accreditation and this status will remain until a follow-up survey is conducted to ensure that the correction has been sustained.

An organization may appeal an accreditation decision by contacting The Joint Commission within five days of confirmation of a PDA. More details are available in the Accreditation Process (ACC) chapter of the standards manual.

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