Most Wanted Interpretations
Reaccreditation Files
The
successful reaccreditation assessment depends on the candidate agency’s ability
to verify consistent performance over a three-year period, particularly
in time sensitive reports and activities. CALEA assessors must verify this
performance primarily through a review of agency reaccreditation files, whether
that file is slated for off-site review, compliance panel review, or on-site
review. Recent on-site assessments indicate that many reaccreditation mangers
are using effective file organization techniques and are able to fully prove
compliance upon first review by the CALEA assessor, while others remain busy
during the assessment correcting multiple deficiencies. The deficiencies are
generally for three common reasons:
- Insufficient
documentation is used to prove compliance over the course of the three-year
period.
- Delinquent or omitted
reports or activities are not fully explained in the file.
- The file is
over-stuffed with irrelevant documentation.
To avoid having these
difficulties during your next reaccreditation assessment, focus on the following
points from the CALEA Reaccreditation Manager Training:
- The relevant time frame
for a reaccreditation assessment extends from the day after the last
assessment to the start of the current assessment.
- Quality control
dictates that all files be reviewed by the agency prior to the
assessment to find missing or outdated Individual Standard Status Reports (ISSRs)
or other important documents. Documents dated prior to the last assessment
should be replaced with documents dated during the three-year award cycle.
This does not pertain to written directives dated prior to that timeframe, yet
still in effect. With those directives, only the proofs listed in the written
documentation field of the ISSR will be updated. In some cases, the documents
may look identical, but the dates of the documents indicate to the assessor
that there has been continuity in the manner in which the agency is complying
or if there have been changes in the manner in which the agency complies.
- Special attention needs
to be applied to the time sensitive “performance” standards. These are listed
in an Appendix in each program’s standards manual. Either complete sets of
documents or “representative samples” are used to prove compliance. For
example, all annual reports relevant to a specific standard having a due date
during the period between assessments are a complete set. One or two samples
of a weekly or daily report for each year preceding the assessment would be
“representative samples.”
- Generally, complete
sets should be in files for quarterly, semi-annual, or annual reports.
Monthly, weekly, daily or per incident reports tend to be placed in the file
using “representative samples.” The decision to use complete sets or
“representative samples” is usually based on the volume of the material on
hand and the need to pare down repetitive documents for your ISSR files. For
example, a complete set of daily reports bearing similar information could be
over 1,000 documents. When representative samples are used to demonstrate
compliance over the three-year period, these should be identified as such on
the ISSR and indicate where others or complete sets can be located (master
files).
·
When no
activity exists in an area requiring a review, or analysis, such as the annual
analysis of grievances, a dated and signed memo indicating why there was
no analysis should be placed in the file. This assists the agency in reviewing
the matter at the appropriate time and lets assessors know the matter was not
just overlooked.
- Avoid
over-stuffed or disorganized files by adhering to the point and intent of the
standard. While it is possible to put all information remotely involved with a
standard in a file, doing so usually does little to prove agency compliance.
This can also create a situation that slows down assessors, as they have to
view material that is of little or no value in proving standards compliance.
The agency then must remove those documents that are not relevant or are
improperly organized or highlighted. An over-stuffed or disorganized technique
tends to indicate the accreditation manager does not fully understanding the
compliance verification process or is attempting to overload and distract the
assessors from weak compliance.
Remember
that your assessors will make compliance determinations based on the documents
presented, interviews conducted, and observations made during the on-site
assessment. Assessors will not verify compliance until they reach the
conclusion, based on the evidence presented, that the agency is performing in
the manner described in the standard. This is not possible when the agency
presents incomplete, scant or outdated documents.
Periodic
training at CALEA Conferences is recommended in order to stay abreast of
effective methods and techniques for organizing accreditation files and
preparing for your next assessment. If you are unable to attend CALEA
Conferences or locally available accreditation training, you should discuss this
disadvantage with your CALEA Program Manager, who will be glad to provide you
with additional assistance.
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