The report from the ad hoc panel will be reviewed and deliberated upon by the Accreditation Committee at its next regularly scheduled meeting. The Accreditation Committee shall be the final decision-making body for all complaints. Based on the Accreditation Committee’s deliberations, the following actions may be taken:
- Continue the accreditation status of the Respondent without change;
- Continue the accreditation status of the Respondent but require the Respondent in its next annual report(s) to detail its remediation efforts and compliance with the specific standard(s) and measure(s) identified by the Accreditation Committee as being deficient to maintain the Respondent’s accreditation status, or, in the case of a Respondent in its fourth year of an accreditation status, in the Respondent’s application for reaccreditation;
- Place the Respondent on probation for a period not to exceed twelve (12) months during which time specific follow-up actions, such as regular reporting or a repeat peer review will be required, and the Respondent’s probationary status will be noted on the PHAB website during the probationary period; or
- Revoke the Respondent’s accreditation.
The Complainant and the Respondent will be advised of the Accreditation Committee’s decision on the complaint, a summary of the process taken to investigate the complaint, and a summary of the findings of the investigation within ten (10) business days of the Accreditation Committee’s decision. No other materials related to the complaint will be provided to the Complainant.
All complaints that result in the naming of an ad hoc panel for investigation, and their associated outcomes, will be reported to the full Board of Directors quarterly.
Complaints, and all associated documentation, will be maintained in PHAB records associated with the Respondent for the remainder of that Respondent’s accreditation cycle, or no longer than five years.
PHAB will not publicly release the complaints received nor the results of the complaint assessments except as they may be compelled to do so by legal process. De-identified complaint data may be used by PHAB to inform its efforts to improve its services and those of accredited health departments.