Outside regular review cycles, Centers may self-report non-compliance with Standards.
1.Centers should report non-compliance with specific standards to the are accreditation committee chair.
3.The Area Accreditation Chair receives the self-report and submits it for review by the Commission.
4.Centers self-reporting non-compliance are assigned a notation in the next scheduled Commission meeting. The notation may be removed by the commission when the center demonstrates compliance.
5.The area accreditation committee chair has no authority to assign/remove notations and/or make a decision on behalf of the Commission. The area accreditation committee makes recommendations to the Commission informed by the ACPE Standards and manuals. The Commission has the final decision on Accreditation matters.
Self-reporting for Standards 300.1 and 308.8.1
1. Centers’ self-reports The plan must be created and submitted at the time the non-compliance is self-reported to the Area Accreditation Chair and must include:
1.1.a description of the non-compliance,
1.2.a narrative demonstrating how the center has brought or is bringing itself into compliance,
1.3.a demonstration, with a time line, of how the plan is working, and
1.4.a plan to prevent recurrence and maintain compliance with the standard.
2. For Standards 300.1 and 308.8.1 the self-report of non-compliance and the accompanying to return into compliance are reported to the Regional Accreditation Chair, who must consult with the regional accreditation committee and follow up with recommendations to the Commission.
3. The center will receive a notation that may be assigned and removed in the same Commission meeting. The only notations that may be assigned and removed concurrently are for Standards 300.1 and 308.8.1.
4.The only notation response that can be reviewed by the area accreditation committee is for Standard 300.1. All other notations’ responses are submitted to the Commission to be assigned a national reviewer.
5.The Area Accreditation Chair will report to the Commission for further action cases of recurrence of non-compliance with any standards.