New Accreditation
Manager Training
Jim Ferrell
Caleb Asbridge
Lynn Odenthal
“When we understand that slide, we’ll have
won the war,”
General McChrystal dryly remarked, one of his advisers
recalled, as the room erupted in laughter.
Why Me?
Drafted?
Volunteer?
Promoted?
Why Me?
What are the skills you need to be a
successful Accreditation Manager?
Organized
Detail Oriented
Persistent
People Skills
Tools of the trade
Tools of the trade
Tools of the trade
The ACA Team At Your Site
The ACA Team At Your Site
Teams are successful when they are focused,
have a short cycle time, and are supported by
the executives.
-Tom Bouchard
The ACA Team At Your Site
Accreditation
Manager
100
200
300
400
500
Support From Above
Can I have
support for this
expensive
project?
Who are
you again?
Support From Above
https://aca.org/standards/benefits.asp
Can I have
support for this
project that will
keep you out of
court?
I am allergic
to legal
action! Go
man go!
Basic File
Construction
What you need to know
Overview:
 Basic
accreditation file construction
 How to demonstrate standard
compliance
 Protocol/Primary Documentation
 Process Indicator/Secondary
Documentation
 Preparation of Documents for review
Time to Shine
Benefits of Solid Audit Files
 Smoother
Audit
 Ensure Positive Results
 Show Positive Operations
Before you begin:
2
Hole Punches
 Buy Folders
 Label folders and tabs
3 minutes
per file
MAX
The Goal:
Show Compliance
ACA File
Components
Identifying Parts of the ACA File

Three Parts of the ACA File
 Compliance
Checklist
 Protocol/Primary Documentation
 Process Indicator/Secondary Documentation
The Compliance Checklist

The “Check Sheet” Lists
 The
Standard
 Facility Status of the Standard
 Protocol/Primary Documentation
 Process Indicator/Secondary Documentation
 Comments
The Compliance Checklist


Maintain Consistency
Rate the File

Signature Page
Ask to Make Copies:
Auditors will take checksheets
Policies:
“written policy, procedure and
practice,” or
Performance Based
Standards
General File Guidelines
 Follow
 Make
a person or process
it clear to outsiders
 Address
 Show
process changes
integrity in paperwork
Thin is in….

Cover and Pertinent pages of
policy

Pertinent documentation pages

Only provide what is necessary
to prove compliance.
Highlighting
Make sure your auditors can find what you are showing them.
Bullets

Standards with bullet points must be
clearly labeled in the files.

Assign numbers to the bullet points and
then label the numbers throughout the file.
Demonstrating
Compliance with the
Standard
Proving a Standard?
Showing that the facility has the
policy, procedures, and/or processes
to demonstrate compliance with the
standard.
 We must prove the standard in
documentation and action

How to Prove a standard
(Demonstrate Compliance)




Show Policy & Procedure where applicable
Show, through Process Indicator/Secondary
documentation, how the facility meets and
documents the standard
Address each point of the standard
Leave no room for question
 Address
the standard
 Choose appropriate documentation**
What to do with
Protocol/Primary
Documentation
Protocol/Primary
Documentation

inserted into the file by level of authority
 Federal
Laws
 State Revised Code
 DAS Rules and Policy
 Agency Policy
 Procedures
Standard Operating Procedures (SOP)
 Local Operating Procedures (LOP)

Protocol/Primary
Documentation HINTS



Do not insert the whole policy or
procedure
Always insert the cover page and
signature page
Then only include pages that cover parts
of the standard
Protocol/Primary Documentation
HINTS



Highlight (yellow) the sections within the policy &
procedure section that relate specifically to the ACA
standard language
Use the most current dated Policy and Procedure.
If a policy or procedure have been revised during a
3 year audit cycle, it is not necessary to place all
versions in the ACA file
If there is more than one document included in the
primary section, then distinguish the different
documents on the checklist and within the
particular sections with some sort of tabs or divider
system labeling documents, P-1, P-2, P-3, etc.
If you are performance based

If your site uses “performance-based”
standards, then a policy or procedure is always
placed in the Protocol/Primary section within
the ACA file. However, if your site has not
gone performance-based and the standard
does not call for written policy or procedure,
then the Protocol/Primary documentation is
optional.
What to do with Protocol/Primary
Documentation
Collect all Protocol/Primary
Documentation relevant to the
standard
 READ (yes, READ) the entire
Policy, Procedure, etc.

 Familiarize
yourself and your staff
with the Policy, etc.
Aligning the Standard and the
Primary Documentation

The facility must meet both the Standard
and the Policy
 Sometimes
your agency requires more
stringent practices than ACA
 ACA will judge you on YOUR OWN policies,
even if they exceed the standard
Examples of Commonly More
Restrictive Policy
Key Control
 Tool Control
 Chemical Control

***Check your work

After gathering documentation, re-read both
Standard and Policy and make sure all points
are met.
Good vs. Bad
Documentation
Own the file and the
documents within
Good Secondary Documentation

Good Documentation
 Complete
 Legible
 Professional
 Contains
a date including a month, day and year
 Copied straight and clean
 Demonstrates policy compliance
 Correct form by policy
Process
Indicator/Secondary
Documentation
Process Indicator/Secondary
Documentation
(a.k.a. B-side)

Facility Forms or Notes to the Auditor
used to demonstrate the process for
the standard

Process Indicator/Secondary s are
only a snapshot of a process and
should be “good.”
Process Indicator/Secondary
HINTS

Do not over document a standard

When a standard denotes time (daily,
weekly, monthly), provide three
consecutive examples
Inspect the Process
Indicator/Secondary
documentation:

Read it: Is it appropriate

Does it say too much?
Inspect the Process
Indicator/Secondary
documentation:





Are all parts of the document
legible?
No crooked copies
No torn corners or edges
No coffee spills
No black marks
Inspect the Process
Indicator/Secondary
documentation:





No 3 hole punches
No doodling on documents
Do not use original documents,
No 2-sided documentation
No Blank forms!
Completed forms should have:






Names
Signatures
Dates
No date gaps in inventory logs
No date gaps in seclusion log entries
If it is not a seven day operation, then
write “day off” beside the date on the
form; do not leave the line blank
Tricks to Process Indicator/Secondary
Documentation
Show and follow the Process
 Address each point of the standard in the
order of the standard.
 Represent both Male and Female
Operations if applicable for your facility

Outside Agency Inspections

Inspection Violations


inter-office
communication
Updated Inspections
Photos

Look at it




Does it prove?
Does it tattle?
Label Photos
Take new
Photos
Every Day is An ACA Day!
Inspect what you expect!
The Three P’s
Policy—Tells the auditor what you intend
to do.
 Procedure—Tells the auditor how you plan
to do it.
 Practice—Shows the auditor that you do it
regularly.

Example

Standard 4-JCF-1B-01:
The facility conforms to applicable federal, state
and/or local fire safety codes. Fire safety
inspections are conducted at the following
intervals:
1)
An annual inspection is conducted by the
authority having jurisdiction or other qualified
person(s);
2)
A monthly inspection is conducted by a qualified
fire and safety officer;
Policy

The Kentucky Department of Juvenile
Justice requires that all facilities conform
to applicable federal, state and local fire
safety codes. Fire safety inspections are
to be conducted annually, monthly, and
weekly to ensure proper compliance.
Procedure

Each facility will arrange for an annual inspection by the State
Fire Marshal (SFM). Any violations noted by the SFM shall be
corrected within the required timeframes. Any need for major
corrective action shall be reported to regional management
and the Quality Assurance Branch.

A qualified Fire Safety Officer (FSO) shall conduct a monthly
inspection of the building and grounds and document this
inspection. The completed report shall be provided to the
Superintendent for review and coordination of corrective
action. All corrective action shall be documented.

A facility staff trained in applicable fire safety codes by the
FSO shall complete a weekly inspection of the building and
grounds and document this inspection. The completed report
shall be provided to the FSO for coordination of corrective
action with a copy provided to the Superintendent.
Practice

What would you use to document this
standard is being met?
What is Your Role?
Obtain copies of annual Fire Marshal
report and corrective action
 In some places, coordinate the Fire
Marshal visit or send reminders to the
responsible party
 Obtain copies of monthly and weekly
reports and corrective action
 Notify facility management if reports or
corrective action are not completed

What is Your Role?
Understand the standard
 Make a list of what you need—reports,
forms, etc.
 Keep a calendar—Know when you need
each item
 Make assignments—Know who you need
each item from
 Be persistent in obtaining documentation

Resources
CAMA—
 ACA—

www.mycama.org
www.aca.org
 Standards
and Accreditation Staff
 Kathy Black-Dennis, Director
 Terri Jackson, Specialist
 Pam Eckler, Specialist
State Juvenile & Adult Correctional
Support Staff
 Fellow Accreditation Managers

Questions???