Accreditation Management Admin Guide

Documentation Index

Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt

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Module: GR-08 Accreditation Management
Audience: Compliance Officers, Administrators
Last Updated: 2025-12-15

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Overview

This guide covers administrative tasks for managing accreditations, standards, surveys, and evidence in Encore Health OS. As a Compliance Officer or Administrator, you are responsible for maintaining accreditation records, tracking compliance, and preparing for surveys.

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Before You Begin

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Prerequisites

• Active user account with Compliance Officer or Administrator role
• GR module enabled for your organization

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Required Permissions

• Create, edit, delete accreditations
• Manage standards and surveys
• Upload and verify evidence
• Generate reports

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Quick Reference

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Managing Accreditations

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Creating an Accreditation

1. Navigate to GR → Accreditations
2. Click New Accreditation
3. Complete the form:

4. Click Save

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Editing an Accreditation

1. Open the accreditation detail page
2. Click Edit in the page header
3. Update fields as needed
4. Click Save

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Changing Accreditation Status

To update status (e.g., from Pending to Active):

1. Open the accreditation detail page
2. Click Edit
3. Update the Status field
4. Add notes explaining the change
5. Click Save

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Renewing an Accreditation

When an accreditation is due for renewal:

1. Open the accreditation detail page
2. Click Renew
3. Enter new effective and expiration dates
4. Update certificate number if changed
5. Click Save

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Managing Standards

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Adding Standards

1. Open the accreditation detail page
2. Click the Standards tab
3. Click Add Standard
4. Complete the form:

5. Click Save

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Bulk Import Standards

For new accreditations with many standards:

1. Prepare a CSV file with columns:
   • standard_number, title, category, description
2. Click Import Standards
3. Upload the CSV file
4. Map columns if needed
5. Click Import

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Updating Compliance Status

1. Click on a standard card
2. Click Edit
3. Update Compliance Status
4. Add verification date and notes
5. Click Save

Or use the quick action:

1. Click the status badge on the standard card
2. Select new status from dropdown
3. Confirm the change

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Linking Standards to Compliance Requirements

Connect standards to your regulatory compliance tracking:

1. Click on a standard card
2. Click Link to Compliance icon
3. Search for related requirements
4. Select requirements to link
5. Click Save Links

Benefits of linking:

• See compliance status from both perspectives
• Avoid duplicate documentation
• Unified reporting

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Managing Surveys

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Scheduling a Survey

1. Open the accreditation detail page
2. Click the Surveys tab
3. Click Schedule Survey
4. Complete the form:

5. Click Save

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Managing Survey Status

Update status as the survey progresses:

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Recording Survey Outcomes

After survey completion:

1. Open the survey
2. Click Edit
3. Update:
   • Status to “Completed”
   • Completion date
   • Outcome notes
4. Add any findings as notes
5. Click Save

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Linking Surveys to Audits

Create an audit record from a survey:

1. Click on a survey card
2. Click Link to Audit icon
3. Either:
   • Link to existing audit
   • Create new audit from survey
4. Click Save

Benefits of linking:

• Track findings and corrective actions
• Unified reporting
• Clear audit trail

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Managing Evidence

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Adding Evidence

1. Open the accreditation detail page
2. Click the Evidence tab
3. Click Add Evidence
4. Complete the form:

5. Click Save

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Using the Document Selector

To link existing documents:

1. Click Select from Library
2. Browse or search documents
3. Select document(s)
4. Click Link Selected

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Verifying Evidence

1. Review the evidence document
2. Click Verify or update status to “Verified”
3. Add verification notes
4. Evidence now shows as verified

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Organizing Evidence

Best practices:

• Link evidence to specific standards when possible
• Use consistent naming conventions
• Set expiration dates for time-sensitive evidence
• Keep evidence current before surveys

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Integration Features

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Compliance Integration

Standards can be linked to regulatory compliance requirements:

1. Purpose: Track compliance from both accreditation and regulatory perspectives
2. Benefits:
   • Single source of truth
   • Unified evidence collection
   • Combined reporting
3. How: Use “Link to Compliance” on standard cards

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Audit Integration

Surveys can be linked to formal audits:

1. Purpose: Track findings and corrective actions
2. Benefits:
   • Formal finding documentation
   • Corrective action tracking
   • Evidence-based follow-up
3. How: Use “Link to Audit” or “Create Audit” on survey cards

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Notifications

The system sends notifications for:

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Reporting

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Status Report

Shows overall accreditation health:

• All accreditations with current status
• Standards compliance rates
• Expiring accreditations
• Recent status changes

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Renewal Tracking Report

Monitor upcoming renewals:

• Expiring within 30/60/90 days
• Renewal application status
• Required documentation checklist
• Key dates and deadlines

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Standard Compliance Report

Analyze compliance across standards:

• Compliance rates by accreditation
• Compliance by category
• Standards needing attention
• Evidence gaps

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Survey Preparation Report

Prepare for upcoming surveys:

• Survey readiness score
• Standards not yet compliant
• Missing evidence
• Action items for preparation

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Exporting Reports

All reports can be exported:

1. Select the report
2. Apply filters if needed
3. Click Export
4. Choose format (PDF, CSV, Excel)

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Best Practices

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Accreditation Lifecycle Management

1. Planning Phase
   • Create accreditation record when pursuing new accreditation
   • Import all required standards
   • Identify evidence requirements
2. Preparation Phase
   • Work through standards systematically
   • Collect and upload evidence
   • Track compliance status regularly
3. Survey Phase
   • Schedule surveys well in advance
   • Use survey prep report
   • Link survey to audit for finding tracking
4. Maintenance Phase
   • Monitor expiration dates
   • Keep evidence current
   • Address findings promptly
   • Plan renewals early

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Evidence Management

• Organize by Standard: Link evidence to specific standards
• Use Document Library: Leverage existing documents
• Set Expiration Dates: Track time-sensitive evidence
• Verify Regularly: Keep verification status current

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Survey Preparation

• Start Early: Begin 6+ months before survey
• Use Reports: Generate prep reports regularly
• Assign Responsibilities: Delegate standard ownership
• Mock Surveys: Conduct internal reviews
• Document Gaps: Create action plans for non-compliance

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Common Scenarios

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New Accreditation Application

1. Create accreditation with “Pending” status
2. Import all required standards
3. Assign standards to team members
4. Begin evidence collection
5. Schedule initial survey when ready
6. Update status to “Active” upon approval

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Accreditation Renewal

1. Monitor expiration dates via dashboard
2. Generate renewal tracking report
3. Update any lapsed documentation
4. Schedule renewal survey
5. Complete survey successfully
6. Use “Renew” to update dates

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Survey Preparation

1. Generate survey preparation report
2. Address all non-compliant standards
3. Fill evidence gaps
4. Conduct internal review
5. Update status as issues resolved
6. Confirm readiness before survey date

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Handling Non-Compliance

1. Mark standard as “Non-Compliant”
2. Create corrective action plan
3. Link to audit if formal finding
4. Track remediation progress
5. Collect evidence of resolution
6. Update status when compliant

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Troubleshooting

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Accreditation not appearing for staff

• Check organization assignment
• Verify accreditation is not filtered
• Confirm user has GR module access

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Evidence upload failing

• Check file size limits
• Verify file type is supported
• Try using document library instead

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Integration links not working

• Ensure target record exists
• Check organization matches
• Verify user has permissions for both modules

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Related Guides

• Accreditation User Guide
• Compliance Admin Guide
• Audit Admin Guide
• Policy Admin Guide

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Need Help? Contact your system administrator.