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Overview Submitting Reports to the NPDB Reporting Medical Malpractice Payments Reporting Adverse Clinical Privileges Actions Reporting Adverse Professional Society Membership Actions Reporting State Licensure and Certification Actions Reporting Federal Licensure and Certification Actions Reporting Peer Review Organization Negative Actions or Findings Reporting Private Accreditation Organizations Negative Actions or Findings Reporting Exclusions from Participation in Federal and State Health Care Programs Reporting Federal or State Health Care-Related Criminal Convictions Reporting Health Care-Related Civil Judgments Reporting Other Adjudicated Actions or Decisions

Reporting Private Accreditation Organization Negative Actions or Findings

Private accreditation organizations are required to report to the NPDB certain negative actions or findings against health care entities, providers, and suppliers. These negative actions or findings are defined in NPDB regulations as a final determination of denial or termination of an accreditation status that indicates a risk to the safety of a patient, or patients, or quality of health care services. The actions taken must be as a result of formal proceedings. The health care entity, provider, or supplier must be licensed or otherwise authorized by the State to provide health care services.

Private accreditation organizations also must report any revisions to a previously reported negative action or finding. For more information, go to Types of Reports in this chapter.

Table E-17 outlines reporting obligations for private accreditation organizations.

Law Who Reports? What is Reported? Who is Reported?
Section 1921 Private accreditation organizations Negative actions or findings by private accreditation organizations Entities, providers, and suppliers

Table E-18 provides guidance on when private accreditation organization negative actions or findings must be reported to the NPDB.

Action
Reportable?
A private accreditation organization's final denial of accreditation to an ambulatory surgery center after finding the facility was noncompliant across a range of standards, including several serious clinical deficiencies that posed a risk to patient safety. Yes
A private accreditation organization's issuance of a provisional or preliminary accreditation to a skilled nursing facility. No
A private accreditation organization's preliminary denial of accreditation status; this action is not final. No
A private accreditation organization's termination of a health care supplier's accreditation for noncompliance with significant policies and procedures required by the accreditation standards related to patient health and safety. Yes
A deferral of a determination regarding an accreditation status. No
Accreditation with a follow-up survey due to noncompliance with specific standards. No

Submitting a Copy of the Report to the State Licensing or Certification Authority

A copy of the Report Verification Document, which private accreditation organizations receive after a report is successfully processed by the NPDB, must be provided to the appropriate State licensing or certification authority.

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