Commission on Accreditation

Purpose, Criteria and Process

The purpose of Commission on Accreditation (Commission) is 

• to determine Level 2 Accreditation for the services of candidate organizations
• to complete its review in an ethical and impartial way and
• to provide suggestions, recommendations, and/or feedback to service providers as it pertains to the Level 2 portion of the report

Service providers must meet Accreditation Level 1 at the 90% level (using the Accreditation Level 1 Measurement System) for their site survey reports to be reviewed by the Commission. Organizations that offer services in multiple regions must achieve Level 1 at the 90% level across all of its regions.

Meetings to review accreditation site survey reports are generally scheduled monthly. When possible, meeting dates will not be scheduled for the month of December or during peak summer vacation times.

Following the Commission meeting, the Accreditation Coordinator will send the service provider a copy of the final report and an accompanying letter. The content of the letter may include, but is not limited to

• the accreditation decision
• the rational for the accreditation decision
• an offer to have a Commission member or designate present the Accreditation Certificate and
• an offer to make up a complementary congratulatory announcement

If follow-up action is required, the letter will include

• an attached schedule that provides details of the deficiency and
• deadlines for making up the deficiencies

A separate mailing will be sent to service providers that have been awarded Three-year Level 2 Accreditation that includes its Accreditation Level 2 certificate, which is signed by the Commission Chair. ACDS offers to cover all or part of the cost of framing the certificate.

Accreditation Decisions

There are three possible Accreditation Level 2 decisions, only two of which are options during the initial review of an organization’s site survey report.

Three-Year Level 2 Accreditation

The highest level of accreditation that the Commission can award is Three-Year Level 2 Accreditation. This decision indicates that the organization

• is in compliance with the standards
• is considered resourceful and innovative (e.g., in its approach to meeting challenges) 
• has shown that it encourages creative thinking and
• has achieved the right to be considered both an employer of choice and a service provider of choice

Deferred Level 2 Accreditation

Deferred Level 2 Accreditation means

• the organization is basically in compliance with the standards but has areas that require corrective follow-up action (e.g., enhanced staff training, more current policy) and
• the Commission believes that the organization has the motivation to address these components within the timeframe it specifies (e.g., three, six or twelve months, or a combination of these as determined by the amount of time the Commission feels is needed to fulfill the requirements)

Once the Deferred Level 2 Accreditation decision has been given, the organization is instructed on how to use the Action Plan and Standards Verification process. Upon completion of the full standards verification process, the Commission will review the Action Plan and determine Accreditation.

Termination of Level 2 Accreditation

The final possible decision is the seldom needed Termination of Level 2 Accreditation. This is not a decision option that the Commission can make at the initial review of an organization’s site survey report. It only becomes an option if an organization has chosen to disregard the standards verification process altogether, or have deferred it beyond the allotted deadlines.

Terminating the Accreditation Level 2 status is determined upon consensus of the Commission members. The organization will still retain its Three-Year Level 1 Accreditation.

Appeal

If an organization has concerns about the Commission’s decision or its objectivity, it may submit a written appeal as per the Appeal Panel process.