Flowchart of the Accreditation Process

Accreditation Administrator (AA) notifies health director, commissioners, board of health chairs and county manager of the pending site visit.
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Health department should submit the Health Department Self-Assessment Instrument (HDSAI) within 90 days after notification by the Accreditation Administrator (AA) that the accreditation process for the department has begun.  The HDSAI should be submitted to the AA at the North Carolina Institute for Public Health.
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After receipt of the HDSAI from the health department, the Site Visit Team (SVT) reviews the HDSAI and supporting documentation, visits the health department, interviews local health department staff and other persons necessary to evaluate compliance with the benchmarks and inspect the facilities in accordance with the benchmarks.
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The SVT will prepare a report that makes a determination as to whether the benchmarks have been met and submit the report to the Accreditation Board (AB) and the local health department within 14 days of the end of the site visit.
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The Accreditation Board meets, reviews the SVT’s report and hears a presentation from the SVT.  In addition, the local health department director will have the opportunity to respond.
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If the local health department requests, the AB will grant the local health department an additional twenty-one (21) calendar days to submit additional written information to the AB. If the local health department submits additional information, the AB shall take action within 90 days of the presentation of the SVT to the AB. If no such request is made, the AB may take action on the SVT’s recommendation or may request additional information from the local health department and defer action on the recommendation to a later meeting.  The AB shall take action within 90 days of the presentation of the SVT to the AB.
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The AB grants a status of Accredited or Conditionally Accredited.
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Accredited Conditionally Accredited
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Accreditation is awarded for four years. If the AB assigns a status of Conditional Accreditation, the local health department may make a written request within ten (10) calendar days for reconsideration of the decision. The written request should state the specific objections to the decision and the basis for those objections.  The AB will act on the request within sixty (60) calendar days.
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Conditional Accreditation is available for up to two years, during which time the health department implements a remediation plan. During the Conditional Accreditation period, the local health department may apply again for Accreditation in accordance with the rules adopted by the Commission.
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If the AB finds that the conditions of the Remediation Plan have been met, the AB will change the local health department status to Accredited. If at the end of two years, Conditional Accreditation is not removed, the health department will be deemed Unaccredited.
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Local health departments should submit the HDSAI no later than 6 months before the expiration date of its accreditation.  The AB will initiate a site visit in accordance with subsection .0202 and take action in accordance with subsection .0203 before the local health department accreditation expires.  The process begins again. Unaccredited

 

Last updated March 30, 2017