Accreditation Handbook

Internal Use Only

• The Review Team will conduct a series of interviews with several field examiners and office personnel including individuals in charge of training, off-site surveillance, internal IT, legal issues, personnel and budgeting. • If necessary, requests for additional files and/or documents may be made. • The Review Team will deliberate on the ratings and complete their preliminary score. • The Review Team will have their exit meeting with the Commissioner, Deputy Commissioner, Agency POC, and any other staff they wish to have present. • The Review Team Leader will lead the exit meeting, but each Review Team member will provide and discuss the findings for the sections he/she was assigned. NOTE: The above timeline and order of events will vary from agency to agency depending upon the availability of staff, complexity of the agency, and concerns identified. Post On-Site Review: After the on-site review portion is completed, the Review Team Leader will draft the final report and receive any feedback from the other Review Team members. VI. Audit Team Review After the Review Team Leader and CSBS Staff have completed their review of the report, it will then be reviewed by the Audit Team. The purpose of this review is to ensure that the findings are fair and consistent with the accreditation standards. The Audit Team typically consists of two members chosen from the same pool of Review Team members described above. However, an Audit Team member cannot review the work product of a Review Team where he/she served as a member. In some instances, a PSC member may serve as an Audit Team member. VII. PSC Review/Vote The final step to the accreditation process is for the Performance Standards Committee to review the final report and vote for or against the accreditation or re-accreditation of an agency. If the agency is approved for accreditation/re-accreditation, then an email from CSBS Staff will be sent to the Commissioner and Agency POC with the final report, scoresheet, and notification letter. Please see APPENDIX F for when an agency is put on probation or de-accredited. Annual Review I. Purpose of the Annual Review For continued accreditation, each accredited agency must complete the Accreditation Annual Review every year that an onsite review is not scheduled. The purpose of the Annual Review is to: • Review recommendations made at the five-year onsite visit to verify where the agency is addressing any concerns noted; • Review new information provided by the agency and the CSBS data analytics area to determine if risks within the agency have increased or declined; • Review and modify any risk levels as needed.

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