Accreditation Handbook

Internal Use Only

E. Review Team Recommendation Based on Accreditation Review When the Accreditation Review Team deems an agency does not meet the minimum standards for initial accreditation or re-accreditation the following steps will occur: 1. Review Team provides a verbal report of its preliminary findings to the agency Commissioner at the exit meeting. 2. CSBS Accreditation staff notifies appropriate CSBS Executive Management—in case the agency contacts CSBS. 3. CSBS staff notifies Chair of PSC of the Review Team’s findings and recommendation. 4. Review Team Lead drafts a report following the normal preparation process and makes his/her recommendation to the PSC. 5. Review Team Lead will have a call with the PSC (normal turnaround would be 30 business days). NOTE: Since the Review Team Lead is meeting directly with the PSC, the PSC can serve as the Audit Team. F. Recommendation Not Based on Accreditation Review In some instances, the PSC may be made aware of facts that can adversely impact an agency’s accreditation status between the five-year accreditation reviews. Information may come from such sources as the annual review process, discussions with the agency, or publications. If an agency fails to meet any of the requirements for continued accreditation, the PSC may vote to place the agency’s accreditation in probation status for a defined period of time or de-accredit the agency. If concerns are raised that warrant additional follow-up by the PSC, the Committee will follow these steps: 1. The PSC Chair and/or CSBS staff will contact the agency via phone call, email, or letter to communicate the basis for concern. 2. PSC will request a written response from the agency by a specified date (usually 30 calendar days) to be submitted to PSC Chair via CSBS Staff. 3. CSBS Staff will provide the response to the PSC members for additional consideration. 4. After reviewing the response, the PSC may request additional information or conduct a targeted review to determine if the basis for concern has been resolved and the agency meets the minimum requirements for accreditation. The targeted review may be either an on-site or off-site review conducted by one or more Review Team members to gather, assess, and verify additional information requested by the PSC. The findings of the targeted review will be provided to the PSC in a memo. a. If the PSC concludes no additional action is needed, the agency will be notified of such in written form. b. If the PSC concludes the agency is no longer meeting the minimum requirements for accreditation, the agency will be notified of the PSC’s decision according to the process detailed in H. Communicating the Decision . 5. If the agency does not provide a response: a. CSBS staff will contact the Commissioner to determine if a response is forthcoming. b. If no response by the agency is planned, the PSC will determine if Probation or De accreditation should be taken.

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