Documentation Index
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Module: GR-08 Accreditation Management
Audience: All Staff
Last Updated: 2025-12-15
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 Health 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
| Task | Navigation |
|---|
| View all accreditations | GR → Accreditations |
| View accreditation dashboard | GR → Accreditations → Dashboard |
| View accreditation details | GR → Accreditations → Click on accreditation |
| View standards | Accreditation Detail → Standards tab |
| View surveys | Accreditation Detail → Surveys tab |
| View evidence | Accreditation Detail → Evidence tab |
| View reports | GR → Accreditations → Reports |
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:
| Body | Description |
|---|
| CARF | Commission on Accreditation of Rehabilitation Facilities |
| State | State licensing and certification agencies |
| NARR | National Alliance for Recovery Residences |
| Other | Other specialized accrediting organizations |
Accreditation Status
| Status | Description |
|---|
| Active | Currently valid and in good standing |
| Pending | Application submitted, awaiting decision |
| Provisional | Temporary status with conditions |
| Expired | Past expiration date, needs renewal |
| Revoked | Removed due to non-compliance |
Viewing Accreditations
Accreditation List
- Navigate to GR → Accreditations
- View all accreditations with status indicators
- Use filters to narrow results:
- Status: Active, Pending, Expired, etc.
- Body: CARF, State, NARR, Other
- Site: Filter by location (if applicable)
- Click on any accreditation to view details
Accreditation Dashboard
The dashboard provides an at-a-glance view of your accreditation status:
- Navigate to GR → Accreditations → Dashboard
- View key metrics:
- Total active accreditations
- Upcoming renewals
- Standards compliance rate
- Scheduled surveys
- 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
| Status | Description | Color |
|---|
| Compliant | Fully meets requirements | Green |
| In Progress | Working toward compliance | Blue |
| Pending | Not yet assessed | Gray |
| Non-Compliant | Does not meet requirements | Red |
| Not Applicable | Standard doesn’t apply | Gray |
Viewing Standards
- Open an accreditation detail page
- Click the Standards tab
- View all standards with their compliance status
- 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:
| Type | Description |
|---|
| Initial | First-time accreditation assessment |
| Renewal | Regular renewal assessment |
| Annual | Yearly compliance check |
| Focused | Targeted review of specific areas |
| Follow-up | Review of corrective actions |
Survey Status
| Status | Description |
|---|
| Scheduled | Date set, awaiting survey |
| In Progress | Survey currently underway |
| Completed | Survey finished |
| Postponed | Delayed to new date |
| Cancelled | Survey not proceeding |
Viewing Surveys
- Open an accreditation detail page
- Click the Surveys tab
- View scheduled and completed surveys
- 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:
| Type | Examples |
|---|
| Document | Policies, procedures, manuals |
| Photo | Facility images, safety equipment |
| Screenshot | System configurations, reports |
| Certificate | Training certificates, licenses |
| Report | Audit reports, assessments |
| Other | Any other supporting material |
Evidence Status
| Status | Description |
|---|
| Pending | Awaiting review |
| Verified | Approved as valid |
| Rejected | Not acceptable |
| Expired | Past validity date |
Viewing Evidence
- Open an accreditation detail page
- Click the Evidence tab
- View all evidence with status
- Filter by standard or survey
- Click to view or download documents
Reports
Available Reports
Navigate to GR → Accreditations → Reports to access:
| Report | Description |
|---|
| Status Report | Overview of all accreditations and their status |
| Renewal Tracking | Upcoming renewals and expiration dates |
| Standard Compliance | Compliance rates by accreditation |
| Survey Preparation | Readiness assessment for upcoming surveys |
Exporting Reports
- Select the report type
- Choose date range (if applicable)
- 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
- Monitor the Dashboard: Check regularly for upcoming renewals and surveys
- Review Standards: Familiarize yourself with requirements in your area
- Support Evidence Collection: Help gather documentation when requested
- Report Issues Early: Notify compliance officers of potential gaps
- 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.
