Complaints

Process for Handling Complaints Regarding Jointly Accredited Providers

August 2015

 

A. Complaint Status and Statute of Limitation

 

1. Complaints are written notifications to the Accreditation Council for Continuing Medical Education, the Accreditation Council for Pharmacy Education, and/or the American Nurses Credentialing Center (“the Joint Accreditors”) by a third party which claim that a jointly accredited provider (“provider”) is not in compliance with the Joint Accreditation Criteria with regard to one or more of its activities (“Complaint”).

 

2. To receive status as a Complaint, the written Complaint must identify the provider, identify the CE activity in question if applicable, and confirm the name, US Postal Service address and contact information of the person making the submission (“Complainant”).

 

3. A Complaint may a) refer to single activities/series, or b) the provider’s entire program of continuing education (“CE”).

 

4. The statute of limitation of the length of time during which a provider must be accountable for any Complaint received is twelve (12) months from the date a live activity ended, or in the case of a series, twelve months from the date of the session which is in question. Providers are accountable for an Enduring Material during the period of time it is being offered for CE, and twelve (12) months thereafter.

 

5. The Joint Accreditors may initiate a Complaint against a provider.

 

B. Procedure for Complaint Review and Provider Response

 

1. The Joint Accreditors will review the Complaint to determine whether it relates to the manner in which the provider complies with the Joint Accreditation Criteria.

 

2. If the Complaint does not relate to the provider’s compliance with the Joint Accreditation Criteria, the Complainant will be advised of the Joint Accreditors’ position and the Complaint process will be closed.

 

3. If the Joint Accreditors determine that the Complaint relates to the provider’s compliance with the Joint Accreditation Criteria, then a letter will be sent which identifies the alleged noncompliance to the provider (“Notice of Complaint”). The Notice of Complaint from Joint Accreditation may include a request for documents or data from the provider. The Joint Accreditors will attach a redacted copy of the Complaint to the Notice of Complaint. The identity of the Complainant will be deleted from the Complaint. To the extent feasible, the Joint Accreditors will not disclose the identity of the Complainant during the Complaint process, but the identity of a Complainant may be evident due to the circumstances of the Complaint, and the Complainant’s identity may be revealed in a legal proceeding.

 

4. The provider shall either admit the allegations of the Complaint or provide a written rebuttal and any information requested by the Joint Accreditors within thirty (30) days of receipt of the Notice of Complaint. The provider’s failure to provide information requested by the Joint Accreditors within the thirty (30) day time limit may contribute to a finding of noncompliance. The provider will be informed in writing that a change of status to Nonaccreditation may occur if the provider has failed to respond to the request for information in the manner stipulated by the Joint Accreditors.

 

C. Joint Accreditation Findings and Decisions

 

1. The provider will be found in Compliance or Not in Compliance for that activity. The completed process and the findings will be kept confidential by the Joint Accreditors, with the exception of the Joint Accreditors’ response to a lawful subpoena or other legal process; provided, however, that the Joint Accreditors reserve the right to make public the noncompliance issue without naming the provider which was in noncompliance.

 

2. The provider will be notified of the finding. If the finding is Not in Compliance, the noncompliance will be described in a Notice of Noncompliance to the provider.

 

a. If an activity is found to be in Noncompliance with Joint Accreditation Criterion 9, Standard for Commercial Support 1 (Independence), Standard for Commercial Support 5 (Content and Format without Commercial Bias), or Joint Accreditation Criterion 6 the accredited provider is required to provide corrective information to the learners, faculty and planners. The provider will submit to Joint Accreditation a report describing the action that was taken and the information that was transmitted. Providers will determine how to communicate the corrective information and are under no obligation to communicate that the activity was found in Noncompliance with Joint Accreditation requirements.

 

b. If the provider is found Not in Compliance, documents related to the Complaint review (such as Notice of Complaint, the Complaint, provider’s response, documentation of corrective action, or monitoring progress report) will be placed in the provider’s file and made available to the survey team and Joint Accreditation ARC reviewer as part of the Joint Accreditation reaccreditation process. In addition, the Joint Accreditors may also take the following actions in response to a finding of noncompliance:

 

i. The Joint Accreditors may require the provider to submit documentation of corrective action within thirty (30) days of receipt of the Notice of Noncompliance;

 

ii. The Joint Accreditors may require the provider to submit a Monitoring Progress Report at a time determined by the Joint Accreditors;

 

iii. The Joint Accreditors may change the provider’s accreditation status to Probation or Nonaccreditation; and

 

iv. If the provider fails to convert Noncompliance to Compliance via documentation of corrective action, monitoring progress report, or other remedial measures, the Joint Accreditors reserve the right to change the provider’s accreditation status to Probation or Nonaccreditation

 

3. At any point in the Complaint process, the Joint Accreditors reserve the right to require an immediate full or focused accreditation survey, including a full or focused self-study report and interview.

 

4. When asked for ‘documentation of corrective action’ the provider will be asked to provide documentation of corrective action to the Joint Accreditors within thirty days of receipt of the Notice of Noncompliance, and will be notified that failure to correct the deficiencies may result in an immediate resurvey which may affect the provider’s accreditation status.

 

5. If the Monitoring Report adequately describes and documents Compliance it will be accepted. If the Monitoring Report does not adequately describe and/or document Compliance it will NOT be accepted.

 

6. Regarding Request for Information or Response: Change of status to Probation may automatically occur at 45 days from the time the provider receives a request for information/response from the Joint Accreditors, if the provider has failed to provide a response or provide the requested information.

 

7. Regarding Documentation of Corrective Action: Change of status to Probation may automatically occur at 15 days after the due date for the notice set by the Joint Accreditors, if the provider has failed to submit the required documentation of corrective action.

 

8. Regarding Monitoring Progress Report: Change of status to Probation may automatically occur at 30 days after the due date for the Monitoring Progress Report set by the Joint Accreditors, if the provider has failed to submit the required Monitoring Progress Report. Each instance of a failure by a provider to respond described in this paragraph shall be a “failure to submit.”

 

9. Change of status to Nonaccreditation may occur at 30 days from the date a provider was placed on Probation for failure to submit information or a response, documentation of corrective action or a Monitoring Progress Report if the provider has still failed to submit the required information and/or documentation. Change of status to Probation or Nonaccreditation for ‘failure to submit’ does not require Board action.

 

10. The Joint Accreditors will send a notice to the provider of a change of status in a manner that confirms receipt (e.g., email, USPS certified mail, FedEx-type courier).

 

11. Except for an automatic change in status due to a provider’s “failure to submit”, a provider’s compliance must be reviewed by the Joint Accreditation Review Committee and the governing boards/commission of the Joint Accreditors in order to either a) change the provider’s accreditation status to Probation or Nonaccreditation or b) proceed with a full or focused accreditation survey, including a full or focused self-study report and interview.

 

Click here to download the PDF version