Corrections_Today_Summer_2025_Vol.87_No.2

STANDARDS & ACCREDITATION

After the ACA Accreditation Audit

By David Haasenritter

T he auditors completed the out brief and are leaving your facility. You are tired and happy your

applicant is required to respond to each non-mandatory expected prac tice found in non-compliance. The response to non-compliance should be emailed to the audit chair using the ACA Response to Non-Com pliance form. Responses to audit findings may be a plan of action, a request to waive the requirement that a plan of action be submitted, or an appeal of the audit findings. Plan of Action (POA) The preferred response to the finding of non-compliance with

a non-mandatory expected prac tice, is to submit a POA that will bring you into compliance with the expected practice. The POA speci fies: the statement of deficiencies; description or summary of actions necessary to achieve compliance; tasks to be completed; the re sponsible agency and personnel for completing each specific task; and timetables to be met for each specific task. These tasks should be attainable and realistic and can be completed within a reason able timeframe. Some POAs may require longer time frames due

facility scored 100 % manda tory and 98.9% non-mandatory

and you think it is over. Well as Yogi Berra used to say “It ain’t over ‘till it’s over.” You still have a few steps to do before you are accredited. During an audit, every expected Yogi Berra

practice is evaluated as compliant, non-compli ant, or non-applicable. During the audit exit interview, the Chair person provides the applicant (applicant is defined as the facil ity or program seeking Accreditation) with a written copy of the ex pected practices found in non-compliance including the reason for the non-compliance. If not provided during the audit, then within two weeks of the conclu sion of the audit, the

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