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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:
- 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outdated Individual Standard Status Reports (ISSRs) or other important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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