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Standards Review Committee

Purpose

Every three years, ACDS draws on the knowledge and experience of service providers, site surveyors and other stakeholders, plus formal and informal feedback, to ensure that the CET Standards

  • are written clearly and concisely
  • reflect the current expectations of and leading developments in the field of Community Disability Services (CDS)
  • addresses or resolves issues identified in the field
  • can be applied consistently, ethically and professionally through the ACDS accreditation survey process

The Review Process

The Standards Review Committee

  • solicits and reviews feedback on the CET Standards
  • reviews
    • the intent of accreditation
    • the accreditation process
    • each CET Standard along with the preamble and indicators for each Standard
    • the documentation that is part of the CET Standards (e.g., Appendices)
  • makes recommendations and suggestions around the intent, content and wording
  • supports the ACDS Standards and Accreditation Department in completing the review and making the revisions

2016 CET Accreditation Standards

ACDS would like to thank all those who participated in the 2015-2016 Standards Review Committee; your time and experience were invaluable to us.

Although the Committee’s formal meetings have ended, ACDS still has much work to do before the 2016 version of the CET Accreditation Standards will be ready for dissemination.

That means there is still time for anyone who has an interest in CET to give us your thoughts. Just contact us at This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Appeal Panel

The Appeal Panel is struck by the ACDS Board of Directors for the purpose of:

  1. Reviewing a service provider's appeal of its CET survey based on its concerns about the survey's objectivity; or
  2. Reviewing a service provider's appeal of the decision of the Commission on Accreditation.

The Appeal Panel is usually comprised of three members:

  1. At least one representative of the ACDS Board of Directors;
  2. An Executive Director of a similar organization; and
  3. A third-party surveyor.

The Standards and Accreditation Manager takes part in Appeal Panel meetings to provide general clarification on the survey process and specific clarification around the survey being appealed. Other people who may be asked to take part in the meeting could include a representative of the organization that has launched the appeal, the survey team leader, or a Commission on Accreditation member.

Commission on Accreditation

The Commission on Accreditation (Commission) is an arms-length body that reviews and renders accreditation decisions on Accreditation Level II site survey reports for organizations that serve the community disability sector.

The purpose of the Commission is to award either Three-year Level II Accreditation or Deferred Level II Accreditation - in an ethical and impartial manner - for the programs or services of organizations eligible to apply for ACDS Level II Accreditation status. Members also give suggestions or recommendations to organizations to address any areas that need to be brought into compliance with the Creating Excellence Together (CET) Level II Standards and, when necessary, maintain communication with the ACDS Board on matters concerning Level II Accreditation, the survey process, and emerging trends.

The Commission consists of eight members who are ACDS members (or from member organizations), have an interest in and knowledge of the Accreditation Level II process, have a commitment to promoting Accreditation Level II surveys; and have experience in any of the following the areas: Persons w/ Developmental Disabilities (PDD), Children with Disabilities (FSCD), Mental Health, Brain Injury, and Seniors. A legal representative chairs Commission meetings.

Meetings to review accreditation site survey reports are scheduled monthly depending on the number of Level II reports that need to be reviewed. When possible, meetings dates will not be scheduled for the month of December or during peak vacation times in the summer.

Interested persons can apply to participate on this committee by sending an Application to Participate on the Commission on Accreditation form to the Standards and Accreditation department.

Exemption Panel and Exemption Process

Exemption Panel

The Exemption Panel is made up of six members who represent Community Disability Services (CDS) and the Ministry of Community and Social Services; Disabilities, Inclusion and Accessibility Division (DIAD, formerly PDD). The Panel only meets when a service provider has applied to be exempt from undergoing a Creating Excellence Together (CET) Accreditation site survey.

Because Panel members must be familiar with the CET review process, members can include site surveyors, the executive directors of CET Accredited organizations, and Regional Designates.

Exemption Panel meetings are conducted by teleconference.

Exemption Criteria

Service providers that provide services to DIAD-funded Albertans must go through a Creating Excellence Together (CET) Accreditation Standards review. But service providers can apply for exemption from the CET survey process if they meet specific criteria.

  • Service providers that do not provide direct service to individuals, and do not provide any type of monitoring, implementation, or follow up.
  • Service providers that provide one-time, sporadic, or infrequent support with no expectation of follow-up or ongoing contact.
  • Service providers that wish to be accredited through another accrediting body that has equivalent standards. Accreditation Equivalency is described below.

Note: Family Managed Services, known in some circles as Self Managed Supports, are exempted from site survey participation.

 Accreditation Equivalency

During February and March 2017, Western Management Corporation conducted an equivalency review on behalf of the Ministry of Community and Social Services; Disabilities, Inclusion and Accessibility Division. The review compared the accreditation standards of five accrediting bodies with ACDS’ Creating Excellence Together (CET) Standards to determine which standards are equal to CET in measuring Quality of Life, Quality of Service, and Organizational Framework.

The Assistant Deputy Minister has endorsed the following recommendations from the Corporation’s report.   

The standards of the following three organizations are deemed comparable across all support and services. Service providers that choose to be accredited through one of these organizations do not need to go through any CET Supplemental review.

  • The Council on Accreditation (COA) Standards
  • The Canadian Accreditation Commission (CAC) Standards have just received equivalency status
  • The Commission on Accreditation for Rehabilitation Facilities (CARF)

The Accreditation Canada (AC) Standards are deemed comparable across all supports and services with the exception of employment supports. Therefore, service providers that choose to be accredited through AC will also be required to go through a CET Supplemental review.

The Canadian Centre for Accreditation (CCA) Standards  deemed not comparable; therefore, organizations will be required to go through a full CET Accreditation review.

Exemption Process

Request for Exemption of a Service

  1. Start the exemption process as soon as your organization receives a one-year letter stating the date of your next CET site survey. 
  2. Prepare an exemption request at least eleven months prior to your organization's scheduled survey, and submit it to the ACDS Director, Services and Accreditation.
  3. The exemption request needs to include information about:
    1. the type of service provided;
    2. if its service is periodic, short term, or one time only;
    3. if there is no direct delivery of services or supports; and
    4. if there is any regular follow-up.
  4. The letter should also describe why the service would be difficult to evaluate through a CET survey.
  5. Be sure to notify your organization's DIAD Regional Designate and copy this person in on any further exemption-related correspondence with ACDS.
  6. The Director will respond to your exemption request with an acknowledgement letter, which is copied to your organization's DIAD Regional Designate.
  7. You may be asked to submit additional supporting information.
  8. If your organization is already accredited through another accrediting body, you will be asked to submit a copy of that body's Accreditation report and/or appropriate supporting documents.
  9. The Director will distribute your original exemption request plus additional information to the Exemption Panel members for independent review.
  10. The Director will advise you of the date and time of the Exemption Panel meeting, and will ask who will represent your organization at the meeting.
    1. Meetings are conducted via teleconference.
    2. The service provider representative will be given approximately 10 minutes to answer the Panel's questions.

Request for Exemption from a Specific Standard

  1. A request for exemption from a specific CET Standard follows the same basic process as exemption of a service, except the basis for allowing exemption is based on:
    1. the nature of the service provided;
    2. the influence and/or impact the service provider has on that area of an individual's life; and
    3. the intent of the Standard as described in the About the Standard section of the CET Manual.
  2. The Panel is charged with determining criteria for exemption to particular Standards.

Exemption Decisions

There are five possible decisions that the Exemption Panel may come to following the Exemption Panel meeting.

Full Exemption

  • The service provider meets the criteria for exemption and does not need to go through a site survey.
  • The service provider will be told whether the full exemption is permanent (providing its services or circumstances don't change) or whether the exemption is only for three years (i.e., until its next site survey).

Partial Exemption

  • Some of the service provider's services fully meet the criteria for exemption, but other portions do not.
  • The service provider will be expected to go through its site survey as scheduled.
  • The survey will only review the portions of its services that don't meet the criteria for exemption.

Supplemental Review

  • Portions of the service provider's services only partially meet the criteria for exemption.
  • The service provider will be expected to go through its site survey as scheduled.
  • The survey will only include the Quality of Life and Quality of Service Standards plus specific Organizational Framework Standards (e.g., the use of positive and restrictive approaches and procedures).

Modified Review

  • The service provider's services only partially meet the criteria for exemption.
  • The service provider will be expected to go through its site survey as scheduled.
  • The survey will be modified to only review those service areas that can be measured.

No Exemption

  • The service provider's services or programs do not meet exemption criteria.
  • The service provider will be expected to go through its site survey as scheduled.
  • The Exemption Panel will notify the service provider of its decision eight months before the scheduled survey.

 

Note: With the exception of a decision for permanent exemption, survey exemptions only apply to the current survey cycle in which they were granted. An exemption request must be made at the beginning of the next survey cycle.

Accreditation Council – Committee

The Alberta Council of Disability Services (ACDS) Board of Directors has approved three Operational Councils (i.e., Membership Council, Workforce Council, Accreditation Council) to assist in the advancement of the focus areas for ACDS. The key purpose of the councils is to be touchstone groups that provide advice and/or expertise on the key directional areas of the organization. Of these three councils, it is the Accreditation Council that supports the Standards and Accreditation department along with its purpose and goals (i.e., to provide accreditation to organizations in the Community Disabilities Services sector).

Being a member of the Accreditation Council provides many ways for seasoned colleagues and emerging leaders to provide expert advice to the program area and to give strategic counsel and support to developments in this area. Membership on the Council opens up opportunities to be champions and leaders in communicating developments regarding standards and accreditation, and to gather feedback and intelligence from the field on the views of the standards and accreditation process as well as best practice ideas. Council members also act as liaisons for ACDS on standards to all other areas of the Community Disability Services Field throughout Alberta.

The Accreditation Council consists of between six and nine members who are ACDS members (or from member organizations), may represent each region of the province, will have an interest in and knowledge of the accreditation process, will have a commitment to improving and marketing Standards and Accreditation; and will have experience in any of the following the areas: Persons w/ Developmental Disabilities (PDD), Children with Disabilities (FSCD), Mental Health, Brain Injury, and Seniors.

The Accreditation Council meets four times a year in the ACDS Calgary boardroom. Members are also welcome to join via teleconference. Administrative support for the Council is provided by ACDS.

Interested persons can apply to participate on this committee by sending an Application to Participate on the Accreditation Council form to the Standards and Accreditation department.

ACDS Head Office

160 3015-12 Street NE
Calgary, AB  T2E 7J2
Ph: (403) 250-9495
Fax: (403) 291-9864
Email: acds@acds.caacds@acds.ca


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