Failing Patients: TJC Provision of Care Standard & Its Impact on Harm & Medical Malpractice
- EvaluCare
- May 28
- 7 min read
Updated: May 29
When a patient seeks care, whether for a fractured wrist, acute chest pain, or a mental health crisis,, they expect their hospital to provide appropriate, timely treatment.
The Joint Commission’s Standard PC.01.01.01, “The hospital accepts the patient for care, treatment, and services based on its ability to meet the patient’s needs,” enshrines this expectation into accreditation requirements.
Yet too often hospitals stretch their scope, attempting to treat patients without the requisite programs, staff, or protocols, setting the stage for preventable harm, regulatory citations, and medical malpractice claims. Hospitals can also fall short on existing programs that although not stretching scope can manage programs in such a way that they fall short.
In this detailed exploration, we will:
Explain the background and purpose of Standard PC.01.01.01
Break out its Elements of Performance (EPs) and illustrate each with real‑world examples
Show how failures under this standard—especially in psychiatric and substance abuse care—directly endanger patients
Discuss the regulatory and legal consequences of non‑compliance, including immediate jeopardy, CMS actions, and malpractice liability
Present case studies where inadequate acceptance criteria led to harm and settlements
Describe how EvaluCare assesses hospital programing, identifies gaps under PC.01.01.01, and supports patients, families, and attorneys in seeking accountable resolutions.
By the end, it will be clear that accepting only those patients a hospital can safely treat is not just good policy, it’s a legal and ethical imperative.
Background: Why PC.01.01.01 Exists
Prior to PSQIA and modern accreditation, many hospitals accepted any and all patients—only to discover mid‑course that they lacked specialized services. A medical‑surgical ward overloaded with behavioral health patients, a rural ED confronted with acute psychiatric crises, or a small community hospital asked to manage opioid withdrawal without protocols all represent scenarios ripe for system breakdowns.
Recognizing this, The Joint Commission (TJC) introduced PC.01.01.01 in 2011 as part of Leadership (LD) and Patient Care (PC) standards, later reinforced in the R3 Report Issue 4: Patient Flow Through the Emergency Department Joint Commission. The intent is to ensure that hospitals at minimum:
Define upfront what services and programs they offer.
Evaluate each patient’s needs against those capabilities.
Accept or refer patients accordingly to guarantee safe, appropriate care.
This proactive stance prevents patients from “falling through the cracks” and becoming victims of negligent system design.
Elements of Performance (EPs) for PC.01.01.01
While TJC does not publicly list EPs for PC.01.01.01 in a consolidated PDF, surveyors evaluate hospitals on the following critical components. Below, each EP is paired with illustrative examples of success and failure. Note these standards change over time and this is not meant to be an exact representation of the standards, rather the spirit of them to communicate importance.
EP 1: Establish Written Criteria for Patient Acceptance
Requirement: The hospital maintains clear, written criteria defining which patient care services, treatments, and programs it provides, or does not provide.Good Example: A hospital publishes a directory stating it offers cardiac catheterization, general surgery, obstetrics, behavioral health stabilization (up to 72 hours), and no inpatient psychiatric services beyond acute agitation management.Failure Example: A community hospital’s website and ED policy are silent on psychiatry. An acutely suicidal patient presents at 3 a.m., is temporarily sedated, admitted to the medical floor, and later harms herself due to lack of psychiatric oversight—triggering an RCA and malpractice claim for “inappropriate acceptance outside service capability.”
EP 2: Communicate Acceptance Criteria to Staff and the Public
Requirement: The hospital ensures clinicians, intake personnel, and the community understand which patients it accepts and how to access care or referral.
Good Example: ED triage staff use a computerized protocol to flag patients needing level 1 trauma activation versus psychiatric evaluation, with printed referral guidelines for local mental health centers.
Failure Example: EMS arrives with a methamphetamine‑intoxicated patient; ED staff attempt full decontamination and restraint without a detox protocol or security—resulting in injury to staff and patient, and a lawsuit alleging “lack of communicated capability.”
EP 3: Assess Each Patient’s Needs Prior to Acceptance
Requirement: Using standardized screening tools or interviews, the hospital evaluates the patient’s clinical, psychosocial, and functional needs against its service definitions. Good Example: Upon arrival, behavioral health patients receive a validated suicide risk screen and substance withdrawal assessment to determine safe placement or transfer. Failure Example: A complex diabetic patient with uncontrolled hyperglycemia and ketoacidosis and comorbidities is taken directly to a critical access hospital without an ICU, then decompensates while being cared for, leading to brain injury. The hospital lacked protocols to screen for ICU‑level needs before admission.
EP 4: Obtain Patient Consent When Necessary for Referral
Requirement: If a patient’s needs exceed the hospital’s capabilities, staff obtain informed consent for transfer or referral, explaining risks, benefits, and alternatives.
Good Example: A stroke patient arriving at a non‑thrombectomy center is lucidly informed of transfer to the nearest comprehensive stroke center; consent documented and transport team readied.
Failure Example: A child with suspected appendicitis taken to a small facility lacking pediatric surgery; the parents were not informed of transfer, and a delayed appendectomy caused peritonitis, sepsis, and a $2 million settlement.
EP 5: Ensure Proper Licensure and Privileging of Treating Professionals
Requirement: Providers treating the patient must hold appropriate licenses and privileges for the services required—whether onsite or via telehealth.
Good Example: Tele‑psychiatry consults are conducted only by psychiatrists licensed in the hospital’s state, documented in the EHR before consult notes.
Failure Example: A hospital permits “curbside” teleconsults by an out‑of‑state psychiatrist without verifying licensure, leading to incorrect medication orders, patient overdose, and medical malpractice verdict for unauthorized practice.
EP 6: Monitor and Reassess Patient Needs Ongoing
Requirement: After acceptance, the hospital regularly reassesses the patient’s evolving needs, transferring or referring if necessary.
Good Example: A surgical patient’s postoperative delirium triggers a geriatric consult and transfer to a step‑down unit with specialized delirium management protocols.
Failure Example: A patient with acute pancreatitis develops respiratory failure, but remains on the general floor 48 hours too long, resulting in ARDS and brain hypoxia. Failure to reassess ICU needs forms the basis for a gross negligence claim.
EP 7: Document Acceptance Decisions and Rationale
Requirement: Clinicians record the decision to accept or not accept care, the criteria used, any referrals made, and informed consent discussions.
Good Example: ED physician document: “Patient meets criteria for STEMI pathway; transfer consent obtained for PCI at Regional Heart Center; EMS notified.”
Failure Example: A patient admitted under “provider discretion” with no documentation of triage criteria or consult. When treatment delays lead to limb ischemia and amputation, the chart offers no defense, directly supporting malpractice that EvaluCare would identifies in reviews.
Why PC.01.01.01 Matters: Patient Safety, Rights, and Equity
PC.01.01.01 safeguards patients from inappropriate acceptance—a root cause of many sentinel events. Hospitals without clear criteria and processes:
Delay Critical Care: Patients languish in less‑equipped units.
Suffer Unnecessary Transfers: Multiple unstable moves compound risk.
Face Consent Violations: Transfers without informed consent breach patient rights.
Experience Health Disparities: Non‑English speakers or uninsured patients may be de facto denied transfer options.
By enforcing acceptance standards, TJC promotes equitable access to the right level of care, reduces preventable harm, and upholds patient autonomy.
Regulatory and Malpractice Consequences of Non‑Compliance
Immediate Jeopardy & Citation
TJC surveyors can tag failure under PC.01.01.01 as an Immediate Jeopardy if patients face serious harm, for instance, when a hospital’s attempt to “treat” psychiatric crises without stabilization services leads to patient assault or self‑harm Joint Commission.
CMS Conditions of Participation
CMS requires that hospitals maintain services necessary for emergency and inpatient care. Demonstrable breaches, such as lack of ICU‑level resources for ICU‑level patients, can trigger decertification and loss of Medicare/Medicaid payments.
Malpractice Proof
In litigation, PC.01.01.01 non‑compliance provides strong evidence of system negligence:
Lack of Defined Criteria shows hospital knowingly accepted patients it couldn’t safely manage.
Missing Documentation underscores that no formal decision or consent occurred.
Resulting Harm (e.g., delayed PCI, inadequate psychiatric care) directly links to negligent acceptance and retention.
Real‑World Malpractice Examples
Example 1: Psychiatric Boarding Gone Wrong
A 32‑year‑old with suicidal ideation arrives at a suburban ED at 2 a.m. No inpatient psychiatric beds are contracted. The hospital boards her in an unmonitored hallway for 24 hours. She overdoses on loose pills and suffers hypoxic brain injury. The family’s lawsuit cites PC.01.01.01: “Hospital had no psychiatric service line yet accepted and retained patient overnight” resulting in a $4.5 million settlement.
Example 2: Substance Abuse Detox Without Protocol
A middle‑aged man with benzodiazepine dependence is admitted for monitoring but no detox guidelines exist. Nursing staff unfamiliar with CIWA‑Ar protocol fail to administer thiamine or taper doses properly; the patient develops delirium tremens and dies. The estate’s claim highlights that the hospital lacked acceptance criteria and protocols for detox—leading to a $2 million malpractice award.
Example 3: Unlicensed Telehealth Misadventure
Amid COVID surge, a hospital uses out‑of‑state tele‑ICU physicians without verifying licensure. A ventilator weaning order is miscommunicated, causing respiratory collapse. The victim’s family sues for negligent credentialing and PC.01.01.01 violation; a jury awards $3.1 million.
EvaluCare’s Approach: From Compliance Audit to Causation Analysis
When hospitals face PC.01.01.01 issues, or when patients believe they were harmed due to inappropriate acceptance, EvaluCare offers:
Case‑Specific Care Review
Review care through a chart abstraction to trace acceptance decisions, screening tools, and documentation.
In cases of discovery, the team can strc stakeholders, triage nurses, admitting physicians, transfer center staff, to uncover informal practices.
Root Cause and Causation Analysis
With enough detail during the medical care review we can identify contributing factors and root cause that led to patient harm.
Tie each failure to documented evidence of standard‑of‑care expectations under PC.01.01.01.
Discovery: Program Assessment & Compliance Audit
Review written criteria, policies, and referral agreements.
Evaluate staff education, communication materials, and EHR order sets.
Benchmark against TJC R3 Report guidance and best practices.
Reports & Expert Testimony
Deliver clear, actionable findings in a report that supports regulatory findings,
Provide expert affidavits on system negligence and appropriate corrective measures.
Advocacy & Recommendations
Provide direct settlement negotiations for patients and families.
Guide families on next steps—complaints to TJC, CMS appeals, or malpractice referrals.
Conclusion: Matching Capacity to Care
PC.01.01.01 strikes at healthcare’s core promise: to treat those we can safely help and refer those who need specialized care. When hospitals overextend beyond their designed scope, whether by default or design, they place vulnerable patients at unacceptable risk. In these moments, non‑compliance is more than a citation; it is a breach of trust and professional duty that too often ends in tragedy and litigation.
Through rigorous assessment, root cause analysis, and compassionate support,
EvaluCare helps patients and families secure accountability and healing when system failures occur. Because every patient deserves to be seen, and only accepted, by those equipped to meet their needs safely and effectively.
Learn more at www.EvaluCare.net or email info@EvaluCare.net
References & Resources
The Joint Commission. R3 Report Issue 4: Patient Flow Through the Emergency Department. Joint Commission
Lexology. Joint Commission’s New Telehealth Licensure Standard PC.01.01.01 EP 35. Lexology
CMS. Hospital Conditions of Participation. 42 CFR 482. Joint Commission
NQF. Serious Reportable Events in Healthcare—2011 Update. Joint Commission
Proliability. Pressure Injury Litigation Trends. Joint Commission
For expert review under PC.01.01.01—including policy audits, incident investigations, and causation analysis, visit EvaluCare Medical Care Review Services. Our team stands ready to ensure every patient’s right to safe, need‑aligned care.
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