An AFS rule has now been re-established. If an organization receives a repeat finding for an indirect standard at a triennial survey that had previously been found on the previous survey, a 45 day follow up survey will occur.
January 26, 2012
Effective January 1, 2012, The Joint Commission has reinstated a 2011 decision rule (AFS02) in the Accreditation with Follow-up Survey category for all accreditation programs, as well as the corresponding decision rule (CFR02, which was CFR06) in the Certification with Review category for all certification programs. The rule is:
AFS02: The organization demonstrates systemic patterns, trends, and repeat findings primarily with indirect impact standards.
This triggers a follow up survey. Once you promise its fixed, it must remain fixed.