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AAHRPP ACCREDITATION PROCEDURES

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Latest Update: July 9, 2019
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the aahrpp accreditation program initial accreditation procedures reaccreditation procedures streamlined reaccreditation procedures for legacy organizations accreditable organizations site visitors recusals council on accreditation granting or denying accreditation categories of accreditation for renewing applicants categories of accreditation for new applicants voluntary withdrawal from aahrpp accreditation limited site visits status reports fees publication of accreditation status annual and other notification reporting mandatory revisits appeals and hearings certificates of accreditation confidentiality protected health information release and indemnification records retention

Categories of Accreditation for Renewing Applicants

Before the end of its then-current accreditation period, an Organization must reapply and be revisited. Following the site visit, the Council on Accreditation makes a decision about the renewing applicant based on the Step 2 application, Draft Site Visit Report, the Organization’s response, and the evaluation of the response. The Council on Accreditation may place the applicant in one of four categories. 

Full Accreditation: An Organization placed in this category continues to meet all the Accreditation Standards, or in the case of an organization awarded Qualified Accreditation, meets all Standards at time of reaccreditation. Regardless of whether an organization is awarded Full Accreditation or Qualified Accreditation at time of initial review, at the time of reaccreditation, AAHRPP awards Full Accreditation for five years, which commences on the date AAHRPP makes the award. 

Reaccreditation-Pending: The Council on Accreditation places an Organization in the Reaccreditation-Pending category until it decides whether to award Full Accreditation, place the Organization on Probation, or to Revoke Accreditation. The Council on Accreditation may place an Organization in the Reaccreditation-Pending category when the Organization does not meet the criteria for Full Accreditation, and the Council believes the Organization is able and willing to commit to take corrective actions to meet the criteria for accreditation within a reasonable time period, usually three months. Based on a review of the Organization’s response to the corrective actions, the Council decides whether to grant Full Accreditation, or place the Organization on Probation.

Probation: The Council on Accreditation places an Organization on probation when the Organization does not meet the criteria for Full Accreditation and cannot make changes within a reasonable time period, usually three months; or does not satisfy the Council that the Organization is taking corrective actions as proposed in the Improvement Plan or Status Report (as described below). An Organization placed in the Probation category must submit an Improvement Plan within three months of the Council meeting when it was placed on Probation. Based on the Improvement Plan, the Council determines the length of time until another accreditation determination will be made, usually seven months (two Council meeting cycles). Based on progress reports and the continued commitment of the Organization, the Council may award Full Accreditation, keep an Organization on Probation, or Revoke Accreditation. At its option, the Council decides whether a Limited Site Visit or other actions are required before making a final accreditation determination. 

Accreditation Revoked: The Council on Accreditation may revoke accreditation when an Organization does not meet the criteria for Full Accreditation, and the Council believes the Organization has demonstrated an inability or unwillingness to take effective corrective action. It may revoke accreditation at any time, without a revisit. In general, historically, an  Organization in this category was placed initially on Probation and did not take the actions to meet the timeline described in its Improvement Plan. Accreditation may also be revoked by AAHRPP for failure to comply with AAHRPP requirements, including those related to the payment of fees, as described here: 

  •  If an Organization fails to submit payment of its annual fee within 90 days of the date on its invoice, it will be placed on Financial Hold by the Controller. Financial Hold means that until an Organization pays its fees, AAHRPP will not process any submissions related to its Accreditation (including but not limited to, Annual Reports, Step 1 Applications, Step 2 Applications). If an Organization does not pay its fees within 6 months of receiving its annual fee invoice, its accreditation will be revoked. 
  • If an Organization fails to submit Accreditation materials by their respective due dates, the Organization will be notified of its failure to submit by the Director of Operations. The Organization will be provided with one extension to its submission deadline, if appropriate. If the Organization fails to meet its extension deadline, the Organization will be presented to the Council for its consideration and determination of the Organization’s Accreditation status. 

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