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Overview

The Accreditation Management feature helps your organization track and maintain accreditations from bodies such as CARF, state licensing agencies, NARR, and other accrediting organizations. This guide covers how to view accreditation information, understand compliance standards, and track upcoming surveys.

Before You Begin

Prerequisites

  • Active user account in Encore OS
  • Membership in an organization with GR module access

Required Permissions

  • All staff can view accreditation information
  • Only Compliance Officers and Administrators can create or edit accreditations

Quick Reference


Understanding Accreditations

What is an Accreditation?

An accreditation is a formal recognition that your organization meets specific quality standards set by an accrediting body. Common accrediting bodies include:

Accreditation Status


Viewing Accreditations

Accreditation List

  1. Navigate to GR → Accreditations
  2. View all accreditations with status indicators
  3. Use filters to narrow results:
    • Status: Active, Pending, Expired, etc.
    • Body: CARF, State, NARR, Other
    • Site: Filter by location (if applicable)
  4. Click on any accreditation to view details

Accreditation Dashboard

The dashboard provides an at-a-glance view of your accreditation status:
  1. Navigate to GR → Accreditations → Dashboard
  2. View key metrics:
    • Total active accreditations
    • Upcoming renewals
    • Standards compliance rate
    • Scheduled surveys
  3. Review charts showing:
    • Accreditation status distribution
    • Standards compliance by category
    • Survey timeline

Accreditation Detail

Click on any accreditation to see:
  • Overview Tab: Key dates, status, contact information
  • Standards Tab: Required standards and compliance status
  • Surveys Tab: Scheduled and completed surveys
  • Evidence Tab: Documentation supporting compliance

Understanding Standards

What are Standards?

Standards are specific requirements that must be met to maintain accreditation. Each standard has:
  • Standard Number: Unique identifier (e.g., “1.A.1”)
  • Title: Brief description of the requirement
  • Category: Grouping (Administration, Operations, Safety, etc.)
  • Compliance Status: Current compliance level

Compliance Status

Viewing Standards

  1. Open an accreditation detail page
  2. Click the Standards tab
  3. View all standards with their compliance status
  4. Click a standard to see:
    • Full description
    • Requirements
    • Linked evidence
    • Linked compliance requirements

Understanding Surveys

What is a Survey?

A survey is an on-site or virtual assessment conducted by the accrediting body to verify compliance with standards. Surveys may be:

Survey Status

Viewing Surveys

  1. Open an accreditation detail page
  2. Click the Surveys tab
  3. View scheduled and completed surveys
  4. Each survey shows:
    • Survey type and date
    • Surveyor information
    • Status and outcomes
    • Linked audit (if applicable)

Understanding Evidence

What is Evidence?

Evidence documents demonstrate compliance with accreditation standards. Types include:

Evidence Status

Viewing Evidence

  1. Open an accreditation detail page
  2. Click the Evidence tab
  3. View all evidence with status
  4. Filter by standard or survey
  5. Click to view or download documents

Reports

Available Reports

Navigate to GR → Accreditations → Reports to access:

Exporting Reports

  1. Select the report type
  2. Choose date range (if applicable)
  3. Click Export to download as PDF or CSV

Key Dates to Monitor

Renewal Dates

  • Accreditation expiration dates
  • Renewal application deadlines
  • Required documentation submission dates

Survey Dates

  • Scheduled survey dates
  • Surveyor arrival times
  • Post-survey follow-up deadlines

Compliance Deadlines

  • Corrective action due dates
  • Evidence submission deadlines
  • Progress report due dates

Tips & Best Practices

  1. Monitor the Dashboard: Check regularly for upcoming renewals and surveys
  2. Review Standards: Familiarize yourself with requirements in your area
  3. Support Evidence Collection: Help gather documentation when requested
  4. Report Issues Early: Notify compliance officers of potential gaps
  5. Stay Prepared: Know your role during surveys

Troubleshooting

I can’t see an accreditation

  • Verify you have access to the correct organization
  • Check if the accreditation is filtered out
  • Contact your administrator if access is needed

A standard shows incorrect status

  • Contact your Compliance Officer
  • Status may be pending verification

Evidence appears missing

  • Check filter settings on the Evidence tab
  • Evidence may be linked to a specific standard or survey
  • Contact your Compliance Officer to upload new evidence


Need Help? Contact your Compliance Officer or system administrator.