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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:

 

  1. Insufficient documentation is used to prove compliance over the course of the three-year period.
  1. Delinquent or omitted reports or activities are not fully explained in the file.
  1. 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  • Quality control dictates that all files be reviewed by the agency prior to the assessment to find missing or outdated Individual Standard Status Reports (ISSRs) or other important documents.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.