How to Prepare for NCASES Accreditation

 

OVERVIEW

From the outset, NCASES copes with the difficulties emanating from Standards which are to be applied nationally, in different states, in different regions, in programs under different auspices, serving different types of individuals and with different organizational purposes.
Neither the Standards nor the accreditation process attempt to dictate a programs purpose or rationale for existence. We believe that to be the function of the state in which the agency exists and the community it serves. Nevertheless, the Standards require that an agency is meeting a community need and the Site Review Team will look for verifying evidence.

An agency, duly licensed or approved by the government and then electing to stand for accreditation responds to a desire for a broader review and to be held to a higher standard than licensing or government approval generally represents.

It is our hope that the Standards and the accreditation process, consciously eschewing specific types of educational models will assure that individuals in special education agencies and services are provided first, and without question, environments that are healthy, safe, comfortable, attractive, and conducive to learning.

Once assurance is evident that such goals have been attained, the accreditation process will help determine how well an agency, by meeting all Standards, transcends differences attributable to different States, regions, auspices and purposes and provides a high quality of special education programs and services appropriate to the needs of its clients.

Philosophy

The philosophy of NCASES is that the Self Study process associated with accreditation leads to more efficient and effective services for individuals with disabilities and their families.

Mission Statement

The mission is to ensure that special education programs and services maintain excellence through demonstrable adherence to a set of established national standards.

The Need for Accreditation

Private Special Education agencies have increased greatly in number in the last two decades. This growth has been in response to gaps in public services and to the desire of parents to provide something different and/or more appropriate. As a consequence of this impetus, independent Special Education has developed into a major service sector for people with disabilities and their families.

Parallel to this trend of private service development, the national concern with accountability to consumers and the rights of individuals with disabilities has risen to major proportions. Public and private education alike have become aware of, and part of, the emphasis in these areas and have been greatly affected by the translation of concern into implementation.

NCASES was established out of concern that quality control be maintained within private Special Education programs and services. The member agencies of the National Association of Private Special Education Centers (NAPSEC) established an independent, private accrediting agency open to all Special Education agencies. NCASES provides a set of standards and a process by which an agency can be evaluated by these criteria.

The character of American accreditation has been private and voluntary. NCASES follows in this tradition by also relying heavily upon self-evaluation and peer review within the accreditation process. The system is intended to maintain and improve quality, while preserving and encouraging innovation and diversity.

Accreditation by NCASES

1. Assures the community that the agency has met best current practices;
2. Identifies for private and public consumers agencies worthy of financial support;
3. Assists prospective clients, families, and public agencies in choosing a service provider; and
4. Assists in the development of agency improvement goals.

The Standards for Accreditation

The key to success of NCASES meeting its objectives is the appropriateness and comprehensiveness of its Standards and their ability to discriminate between superior quality and mere adequacy. The Standards were developed with input from private and public sector-human service professionals, parents, funders, and higher education. The Standards will be systematically reviewed and revised based on continuing input from the special education field.

In order for an agency to be eligible for NCASES accreditation it must comply with 100% of the Core Standards, which appear in bold type in the Standard and Self Study sections of the NCASES Manual, and comply with 90% of the remaining Standards for Accreditation listed in the manual. To comply with Day Special Education standards the agency must complete the Standards for Accreditation. To comply with other service areas the agency must complete the Standards under each specific service area for which it applied - Special Education within Residential Settings.

For any Standards that a program determines are non-applicable to their program a written explanation for each must be provided with the self study when completed and returned to the NCASES Office. The team, when on site, will determine if each Standard listed is non-applicable. No Standard that requires a policy can be determined non-applicable. For those Standards, a policy must be written stating that the Standard requirement is not done by the program. For example, if the Standard is in regard to research and the program does not do research, the porgram must have a policy that states they research is done by the program.

Applicant Status

Once the agency formally submits the letter of intent, completes the NCASES application, and submits the required application fee, it achieves "applicant status." Applicant status expires one year following receipt of the above materials. NCASES reviews the preliminary application information and, upon preliminary approval, provides the necessary accreditation materials to begin the Self Study. The agency submits half of the accreditation fee when the accreditation materials arrive with the invoice and the remaining amount is collected before the Site Review Team arrives on site.

The Self Study

Preparing for the Self Study and carrying it through constitutes one of the most valuable outcomes of the total accrediting process. It not only provides information used in the evaluation of the agency, but is an opportunity for the agency to involve its entire staff and governing board in the process of agency examination of structure, policy, and procedures.

Unless these preparations are given ample time and involve widespread participation of the staff, board, and others, the benefit to the candidate agency is reduced and Site Review Team work will be hampered. NCASES recommends broad-based participation in the Self Study process, including key staff, board members, families and others, as appropriate.

In preparing for the Self Study the agency should appoint one staff member to be responsible for an individual section of the standards. This will allow agencies to assign different areas to staff based on their expertise, which will enhance the process when the staff meets as a team to organize the entire accreditation package.

Each staff member should have a separate file for each standard in his/her section. The file will hold the proof that the standard has been met. This can be done by simply including the policy required, the agency’s Mission Statement or depending on the Standard in question, it may require proof in practice that the standard has been met. Refer to the italicized information following each Standard for further instruction.

Standard 1. is a Core Standard – it is written in bold print. Standard 36. is not a Core Standard – it is not written in bold print.

EXAMPLE…


ORGANIZATION

The organization is structured and governed for the purpose of providing educational and related services to individuals with special needs.

Mission

 
____1. The organization defines its mission and purpose and establishes a program of educational and related services for its attainment. (In bold type – a Core Standard).

Review copy of Board authorized mission statement and minutes of Board meeting at which the mission statement was authorized.

Accountability

 
____36. Procedures are available for staff and clients/students to alert the organization's administration and governing body to changing community conditions or other matters of concern to the organization.
(Not a Core Standard – not in bold).

Review written procedures, interview staff and client/students. Review staff meeting notes.

A copy of the written policy documentation that shows compliance with each standard, and an example of how the standard is met in practice (for those Standards where an example is needed) written out for the Team to review.

Standard 1. would not need an example, this standard can be proven by placing a copy of the mission statement with a copy of the Board minutes where the mission statement was approved in the file.

Standard 36. is an example of a Standard that requires an example to show it is also met in practice. This folder would contain a copy of the policy or a page stating the name of the manual, the section of the manual and/or the page number where the policy is located.

Your example could be a copy of the staff manual or the name of the manual with the section and/or page number in the manual where the policy is located, a copy of a policy stating that all staff has received a copy of the manual and have signed a document stating the manual has been received and the policy has been read (this signed document would also be in each employees personnel file). The agency could use a suggestion box, or hold meetings where the agenda or the minutes clearly state this type of information is exchanged. These are all examples of how the policy is also met in practice at an agency.

Having the information in order, in folders labeled by section and Standard number will help the process go smoothly for both the agency and the site team. Leaving no surprises for the agency and the Team once they are on site.

In areas where the agency finds it is lacking proof of compliance in policy or practice or both, now is the time to address these areas by developing and implementing new policies and procedures to ensure the agency will be in compliance when the Site Team is on site. This is one of the biggest benefits of NCASES Accreditation - making needed improvements as you go through the Self Study process that will further advance your agency’s mission and goals.

Once staff feels that it has completed the self study, you should gather the entire working group together to review all the standards and revisit any standards that may not be in full compliance. At this point, any problem areas should be identified and policies developed, if needed.

Once you feel that self study is successfully completed and proof exists to meet all the standards. Fill out the “Self Study - Final Analysis” that is located at the end of the Self Study Section in your manual, and fax  or email it to the NCASES office at napsec@napsec.com / 202-434-8224.

The Self Study should be returned to the NCASES office at a minimum of 60 days prior to the Site Review Team visit to allow NCASES to examine the material prior to setting up the site visit.

The agency should include five sets of dates that it would like for NCASES to schedule a site visit. The dates should be listed in order of the agency’s preference – 1st, 2nd, 3rd, 4th & 5th. The Dates should be for a Monday, Tuesday and Wednesday. The Site Team will arrive on Sunday evening to prepare for the weeks activities. 

The Site Review Team Visit

NCASES will review all documents as described previously and select members for the Site Review Team and schedule dates with the agency for the site visit.

The Site Review Team

The Site Review Team will be comprised of experienced professionals from Special Education programs and services, similar to the one being reviewed, and other relevant persons. All team members will have experience with program review and be specially trained for their assignment.

The names of the site reviewers will be sent to the agency prior to the actual visit. If the agency believes that a proposed site reviewer, because of prior association of activities with the agency or its staff, would be unable to render an objective review, the agency has the option of rejecting the site reviewer(s) and requesting a different reviewer(s). Confidentiality of this process will be strictly observed.

Function of the Site Review Team

The Site Review Team will review the agency against the NCASES Standards. They will verify information supplied in the Self Study, gather additional data on agency operation and performance, and assess the agency's level of compliance on the provisions. The Team will not provide consultation to the agency. Board and staff of the agency should not expect the Team to consult on problems found in the course of the accreditation site visit. They are not authorized to state whether an agency will or will not be accredited. This decision lies solely with the NCASES Commission.

Cost of Site Review

The cost of the Site Review includes the accreditation fee, travel expenses, lodging and meals associated with the site visit. The agency is responsible for selecting a hotel and making reservations for the team at a minimum a month in advance of the site visit. The agency needs to inform the hotel that it should be billed for the Site Team’s stay and meal expenses – individual Team members do not pay for hotel expenses or those meals that were charged to their hotel room during the site visit. When the Team returns from the site visit, they will submit their remaining expenses to the NCASES office and once the entire team has submitted their expense forms, NCASES will invoice the agency for the Team’s expenses.

Schedule of On-Site Activities

It is the responsibility of the agency Director/Chief Executive Officer to arrange a tentative schedule for the on-site review based on the NCASES’s Accreditation Process Handbook and discussion with the Team Leader. This schedule should be received by the Team Leader prior to the Teams arrival at the agency. The handbook explains the usual activities conducted on-site and suggested length of time for each. The Team Leader will contact the agency in advance to discuss these issues with the designated agency contact.

These activities most often include: an Orientation Conference with the agency executive and chair or designee; tour of the agency; interview with clients and staff members at all levels of responsibility and governing and/or advisory board members; a sampling of case records, personnel files, financial records, and minutes of board and committee meetings; and observation of activities not specially scheduled for the reviewers. The Team Leader, on the basis of the analysis of the Self Study, may request time be allotted for additional activities not necessarily covered in the handbook. Site visits require a maximum of two and half days. If, based on unusual circumstances, additional time is required this would be worked out in advance of the site team’s arrival.

The Report

At the completion of the site visit the Team Leader, with assistance from the team members, will complete the Site Review Team report. In this report, the reviewers will provide detailed information regarding the agency's level of compliance with NCASES Standards.

The report will be submitted to the Executive Director/CEO of NCASES who will then send it to the agency Director for review. The agency will have the opportunity to respond in writing to the factual statements and evaluation in the report before its submission to the NCASES Commission.

The Accreditation Decision

The report of the Site Review Team will be sent to the NCASES Commission for action. Final authority to award, defer or deny accreditation rests with this body. For more detailed information on these processes consult the NCASES Accreditation Handbook.

Confidential Information

The NCASES Commission will hold in confidence all information about agencies learned during the review for accreditation. The NCASES Commission has the right to make known the decision regarding an agency's accreditation. The NCASES Commission will not release any other information gathered during the accreditation without the written permission of the agency. Information gathered during the accreditation or reaccreditation process includes documents, reports, narratives and evaluations submitted with the application and agency Self Study, observations, reports and work notes of the Site Review Team and the deliberations of the NCASES Commission. These documents are destroyed after the accreditation determination is made.

Litigation Acknowledgment

It is required of all applicant agencies to fully disclose all pending legal matters in which they are involved. Upon review of such matters, a decision will be rendered by the NCASES Commission regarding whether or not the applicant agency is allowed to continue the accreditation process. Decisions by the Commission will be final and determined based upon the following principles:

Litigation pending against an agency may be a deterrent to continuing the accreditation process, they are:
* Abuse or neglect
* Fiscal mismanagement or fraud
* Criminal activities not otherwise specified

Litigation pending against an agency due to non-criminal acts of a civil nature may not be construed as a deterrent to continuing the accreditation process.

Please note...

Concluded litigation actions within the previous seven years must be disclosed to the NCASES Commission by the agency with a synopsis of any actions taken by the agency to comply with court orders and/or deter future litigation of a similar nature. Please ensure that this information is provided to the Site Team while on site.