Accreditation Report - Lee Adjustment Center - WC 2026 (Final Report).pdf

American Correctional Association

Accreditation Report

Commission on Accreditation for Corrections

CoreCivic Lee Adjustment Center

Beattyville, Kentucky

The mission of the Commission on Accreditation for Corrections is to upgrade and improve practices and conditions in adult and juvenile correctional facilities and programs through an accreditation process which is founded on a commitment to accountability, professionalism and respect for basic human rights and which recognizes sound and effective correctional practices, while striving towards excellence in the field of corrections.

April 10, 2026

CoreCivic

Lee Adjustment Center

Beattyville, Kentucky

Congratulations!

It is a pleasure to officially inform you that the Lee Adjustment Center was accredited by the Commission on Accreditation for Corrections at the 2026 Winter Conference on

February 7, 2026, in Long Beach, California.

Your accreditation represents the satisfactory completion of a rigorous self-evaluation, followed by an outside review by a team of experienced, independent auditors.

Every profession strives to provide a high quality of service to society. To know that you, your staff, and other officials are complying with the requirements of the accreditation process is indeed a statement of a high level of commitment to the staff and people under your care.

On behalf of the American Correctional Association and the Commission on

Accreditation for Corrections, thank you for your commitment to the corrections profession and to the accreditation process.

Sincerely, Thomas Stickrath, Chairperson

Commission on Accreditation for Corrections

For Immediate Release

Lee Adjustment Center Awarded National Accreditation

Thomas Stickrath, Chairperson of the Commission on Accreditation for Corrections (CAC), and David Haasenritter, Director of Standards and Accreditation, American Correctional

Association recently announced the accreditation of the Lee Adjustment Center. The award was presented in conjunction with the 2026 Winter Conference on February 7, 2026, in Long Beach, California.

In presenting the award, Thomas Stickrath, Chairperson of the CAC, and Ricky Dixon, President of the American Correctional Association (ACA), complimented the facility on their professional level of operation and their success in completing the accreditation process. The agency is one of over 1,265 correctional organizations currently involved in accreditation across the nation.

The accreditation program is a professional peer review process based on national standards that have evolved since the founding of the Association in 1870. The standards were developed by national leaders from the field of corrections, law, architecture, health care, and other groups who are interested in sound correctional management.

ACA standards address services, programs, health care and security operations essential to effective correctional management. Through accreditation, an agency can maintain a balance between protecting the public and providing an environment that safeguards the life, health, and safety of staff and offenders. Standards set by ACA reflect practical up-to-date policies and procedures and function as a management tool for agencies and facilities throughout the world.

The three-year accreditation award granted to the Lee Adjustment Center does not signal the end of their involvement in the accreditation process. During the award period, staff will work to improve any deficiencies identified during the audit and maintain continuous compliance with the standards.

Congratulations on your accreditation award! You are now a member of the elite in achieving correctional excellence. The certificate you have received is but a small symbol of the enormous dedication and commitment demonstrated by each and every member of your staff to the accreditation process, and I urge you to display it prominently as a continual reminder of the level of professionalism achieved. This is just the beginning of your journey, however, for the true test of excellence is the test of time. It is critical that your operation be able to sustain this achievement over time and be constant through both prosperity and adversity.

Achieving American Correctional Association Accreditation means you have demonstrated your dedication to getting the job done right, and that you are holding your agency to a higher standard.

Thank you for your commitment to the American Correctional Association and the accreditation process.

David Haasenritter, Director Standards and Accreditation Department American Correctional Association

Overview of the American Correctional Association

The American Correctional Association (ACA) is a professional membership organization composed of individuals, agencies and organizations involved in all facets of the corrections field, including adult and juvenile services, community corrections, probation and parole and jails. It has thousands of members in the United States, Canada and other nations, as well as over 100 chapters and affiliates representing states, professional specialties, or university criminal justice programs. For more than 155 years, ACA has been the driving force in establishing national correctional policies and advocating safe, humane and effective correctional operations. Today, ACA is the world-wide authority on correctional policy and expected practices, disseminating the latest information and advances to members, policymakers, individual correctional workers and departments of correction. ACA was founded in 1870 as the National Prison Association and became the American Prison Association in 1907.

At its first meeting in Cincinnati, the assembly elected Rutherford B. Hayes, then governor of Ohio and later U.S. president, as the first president of the association. At that same meeting, a Declaration of Principles was developed, which became the accepted guidelines for corrections in the United States and Europe. At the 1954 annual Congress of Correction in Philadelphia, the name of the American Prison Association was changed to the American Correctional Association, reflecting the changing philosophy of corrections and its increasingly important role in society.

Since that time, ACA has continued to take a leadership role in corrections and work toward a professional unified voice in correctional policy. In recent years, one of the association’s major goals has been the development of national and international policies and resolutions of significant issues in corrections. Policies are considered for ratification at the Association’s two annual conferences and ratified policies are then widely disseminated.

Since its formation, ACA has also had a major role in designing professional standards, and more recently performance based standards and expected practices, for correctional organizations. Since the early 1980s ACA has been involved in a program of accreditation to recognize programs representing excellence in more than 20 different disciplines within the field, with emphasis on evidenced based practices.

Membership in ACA is open to any individual, agency, or organization interested in corrections and the purposes and objectives of the association. Members include the majority of state, local, provincial, and territorial correctional agencies, community corrections, individual correctional institutions, local jails, pretrial programs and agencies, juvenile justice programs, schools of criminal justice in colleges and universities, libraries, and various probation, parole, and correctional agencies. Many of ACA’s members are employed at federal, military, private, state, and local agencies.

Organizational Purposes of the American Correctional Association

Among the most significant purposes of the Association as outlined in its Constitution, are:

➢ To provide a professional association of persons, agencies, and organizations, both public and private, who hold in common the goal of improving the profession of corrections and enhancing their contribution to that profession.

➢ To broaden and strengthen support for the Association’s goals by advocating

Association policies, resolutions, positions, and standards to policymakers and the public and by forming coalitions with other professional organizations sharing these goals.

➢ To develop expected practices for all areas of corrections and implement a system for accreditation for correctional programs, facilities and agencies based on these excepted practices. Where feasible, excepted practices shall be based on performance outcome.

➢ To conduct or sponsor corrections conferences, congresses, institutes, forums, seminars and meetings.

➢ To publish and distribute journals and other informative materials relating to criminology, crime prevention, and corrections and to encourage and stimulate research of these matters.

➢ To promote recognition of corrections as a profession, and those who work in corrections as professionals, and to ensure validity of that recognition by encouraging the recruitment and development of highly qualified corrections professionals, and by developing and implementing a certification program for corrections professionals

In carrying out these purposes, ACA supports programs for policy analysis, demonstration, effective delivery of health services to offender populations and research. ACA also provides testimony, consultation, publications, conferences, workshops, and other activities designed to stimulate constructive action regarding correctional issues.

Organizational Structure of the American Correctional Association

Executive Committee

The Executive Committee is composed of the elected officers of the Association -president, vice president, treasurer, two Board of Governors members, the immediate past president, the president-elect, and the ACA executive director. The Executive Committee meets at least quarterly and exercises most of the powers of the Board of Governors during the intervals between meetings of the board.

Board of Governors

ACA’s bylaws vest control of the Association with a 19-member elected Board of Governors composed of the officers of the Association and five at-large members. The 19 elected governors shall general reflect the Association’s composition. The following areas of practice shall be represented by at least one board member:

Correctional Administration Detention Institutions Education Juvenile Health Care Probation Community Programs Parole, Aftercare or Post-Release Supervision

Delegate Assembly

The Delegate Assembly is composed of delegates from the professional affiliates, geographical chapters, membership at-large, Executive Committee, Board of Governors, Past Presidents of ACA, and representatives of each military service. The Delegate Assembly can establish policy, define association positions on broad social and professional issues, and determine major programs and legislative priorities. They meet at least twice annually, at the Winter Conference and Congress of Correction.

Committees

The majority of the Association’s activities take place through committees. In this way, the association collectively benefits from the involvement and contribution of the hundreds of individuals who function on the various committees. Ad-hoc committees are appointed by the president of the association.

Affiliates and Chapters

Affiliates and state chapters are major features of the Association’s structure. They represent professional, regional, and state groups across the United States and Canada.

Affiliates and chapters contribute to the professional development of all members by providing consultation in their respective areas of interest and by participating in seminars and workshops at ACA’s annual conferences.

Major Activities of the American Correctional Association

Standards and Accreditation

Perhaps ACA’s greatest influence has been the development of Expected Practices and the accreditation process. ACA Expected Practices address services, programs, and operations essential to effective correctional management. Through accreditation, an agency is able to maintain a balance between protecting the public and providing an environment that safeguards the life, health, and safety of staff and offenders. Expected Practices set by ACA reflect practical up-to-date policies and procedures and function as a management tool for correctional agencies internationally. The Standards and Accreditation Department manage the expected practices for all standards manuals and the accreditation process. The department conducts training on the accreditation process and auditor training.

Legislation

The American Correctional Association is involved with all major issues affecting corrections today. Members and ACA staff maintain close working relationships with committees of the U.S. Congress and all federal agencies and groups whose decisions affect correctional policy.

To ensure that the concerns and issues of the corrections profession are represented in proposed legislation and public policy, ACA’s legislative liaison is addressing legislative and government concerns that will impact the corrections profession. ACA has established partnerships with Brooks Bawden Moore’s and other national policy making organizations to present a strong collective voice for correctional reform throughout the world.

Professional Development

The Office of Professional Development is ready and equipped to assist you with professional growth and development. Our team of training and development professionals offers expertise, consultation, and professional development services that are comprehensive, affordable, and flexible. We take pride in providing you with relevant, innovative, and high-quality training solutions to support your quest to learn, grow, and excel as a corrections professional.

In addition to curating educational programming for the Association’s bi-annual conferences, the Association offers a Corrections Certifications Program (CCP) for professionals, across all disciplines and correctional settings, to affirm your knowledge and experience in the field.

If you are interested in self-paced learning opportunities, you are encouraged to enroll in ACA’s e-learning courses that allow you to select courses aligned with your immediate professional development needs.

In partnership with leaders and agencies, our team creates professional development experiences customized to the unique needs and goals of teams, facilities, agencies and organizations, and communities of corrections professionals. We design customized training solutions for professional teams that include, but are not limited to, focus on the following topics:

• Leadership Development Training (for leaders at all levels of the agency/organization)

• Leadership Coaching (for leaders at all levels of the agency/organization)

• Organizational Culture Training

• Organizational Development Training

• Performance Improvement Coaching and Training (inclusive of Lean/Six Sigma approach)

• Professional Development Training (skill-based and general topics)

• Strategic Planning (consultation AND retreat planning and facilitation)

• Team Building and Team Development Training

• Technical Corrections Training

• Crisis Intervention and De-escalation

Within our association, your membership has benefits. As a new member, you receive member-only pricing. We encourage you to continue exploring the professional development resources that are within your reach. Take advantage of the opportunity to advance, connect, and achieve with ACA.

For additional information about Professional Development, please visit aca.org.

Office of Correctional Health

American Correctional Association is committed to its mission of improving practices in correctional systems by helping agencies provide correctional populations with safe and effective health service delivery. ACA is the leader in setting international and national standards for the quality of life and safety of correctional systems. ACA’s Office of Correctional Health serves ACA members, jurisdictions and its affiliates by supporting health services programs for the effective delivery of health to offender populations. We offer comprehensive services, support, and resources to help correctional facilities provide security and quality care for the offender population.

The professional certification program recognizes the expertise and integrity of correctional health care professionals in nursing, nurse management, and behavioral health. It promotes continued learning to improve health services within corrections. Training to prepare for certification is available through on-site sessions, webinars, and training packets.

Publications

The Communications and Publications Department at ACA produces trusted resources tailored for corrections professionals. We plan, publish and promote a wide range of materials, including books, standards and expected practices manuals, a quarterly flagship magazine, newsletters, social media, electronic media and graphics, all designed to support correctional staff, administrators, trainers and researchers. Should you have any questions, please email us at publications@aca.org.

The following are just a few of the many publications that ACA offers:

Corrections Today is the major corrections magazine in the United States.

Published seven times a year, it focuses on the interests of the professional mailto:publications@aca.org correctional employee and administrator. Articles include reports of original research, experiences from the field, discussion of public policy, and the perspectives of prominent practitioners and academicians.

Correctional expected practices are the most significant improvement in correctional programming. As the basis for accreditation, they give administrators a nationally recognized system for upgrading and improving their correctional services. The Association currently publishes over 28 manuals for every correctional discipline.

Conferences

ACA hosts two national conferences each year that attract more than 5,000 professionals from all aspects of corrections; the Winter Conference held in January, and the Congress of Correction, held in August. These events include a variety of workshops, exhibits, and seminars devoted to addressing topics specific to the corrections profession.

Overview of the Commission on Accreditation for Corrections

The Commission on Accreditation for Corrections (CAC) is a private, nonprofit organization established in 1974 with the dual purpose of developing comprehensive, national expected practices for corrections and implementing a voluntary program of accreditation to measure compliance with those expected practices.

The Commission was originally developed as part of the American Correctional Association. In 1979, by joint agreement, the Commission separated from the Association in order to independently administer the accreditation program. Between 1978 and 1986, the organizations shared the responsibility for developing and approving expected practices and electing members of the Commission. On November 7, 1986, the Commission on Accreditation for Corrections officially realigned itself with the American Correctional Association.

The Commission is governed by a Board of Commissioners who reflect the Association’s composition, including adult and juvenile components. The responsibility of rendering accreditation decisions rests solely with the Commission.

They represent the following specific categories:

Architecture

Correctional Administration Juvenile Institutions Probation Parole, Aftercare or Post-Release Supervision Community Programs Detention Education Health Care Legal

Association Staff

Accreditation activities are supported by the staff of the American Correctional Association, Standards and Accreditation Department, under the leadership of the director of the department. Standards and Accreditation Department staff is responsible for the daily operation of the accreditation program. Agencies in the process have contact primarily with the accreditation specialist responsible for their state or agency.

Auditors

Auditors are corrections professionals who have been selected, trained, and certified by the Association. These individuals perform the field work for the Association which includes providing assistance to agencies working toward accreditation and conducting on-site audits of agencies to assess compliance with program requirements. In certain cases, when the Commission believes it necessary, they monitor agencies to ensure maintenance of the conditions required for accreditation. Teams of auditors, referred to as Visiting Committees, are formed to conduct compliance audits of agencies seeking accreditation and reaccreditation.

All auditors have a minimum of five years of corrections experience, have received recommendations from an agency administrator, have worked in ACA accredited facility or agency and have demonstrated knowledge in the substantive area(s) in which they are engaged to assist the Association. In addition, all auditors must successfully complete the auditor orientation course, participate in an ACA sanctioned training every three years and be members of the ACA in good standing. All auditors are approved by ACA.

Performance Based Standards and Expected Practices Development

Development of the traditional ACA standards began in 1974 with an extensive program of drafting, field testing, revising, and approving them for application to all areas of corrections.

Since then, local, state, national, and international correctional facilities and programs have adopted the traditional standards, performance-based standards, and expected practices as outlined in ACA’s accreditation manuals, for implementation through accreditation.

In the development of expected practices, the goal was to prescribe the best possible practices that could be achieved in the United States today, while both being realistic and practical.

Steps were taken to ensure that the expected practices would be representative of past standards development efforts, reflect the best judgment of corrections professionals regarding good corrections practice, recognize current case law, and be clear, relevant, and comprehensive. The expected practices development and approval process has involved participation by a wide range of concerned individuals and organizations. Twenty-eight manuals of performance-based standards and expected practices are now used in the accreditation process:

Performance-Based Core Jail Standards Performance-Based International Correctional Core Standards- Adult Performance-Based International Correctional Core Standards- Juvenile Performance-Based International Correctional Core Standards- Mexico Standards for International Correctional Training Academy Performance-Based Standards and Expected Practices for Adult Correctional Institutions Performance-Based Standards for Adult Community Residential Services Performance-Based Standards and Expected Practices for Adult Local Detention Facilities Performance-Based Standards for Adult Probation and Parole Field Services Performance-Based Standards for Correctional Industries Performance-Based Standards for Juvenile Correctional Facilities Performance-Based Standards for Therapeutic Communities Performance-Based Health Care Standards for Adult Correctional Institutions Performance-Based Health Care Standards for Adult Local Detention Facilities Performance-Based Health Care Standards for Juvenile Correctional Facilities

Performance-Based Standards and Expected Practices for Transportation of Inmates Standards for Administration of Correctional Agencies Standards for Adult Correctional Boot Camps Programs Standards for Adult Correctional Institutions Standards for Adult Parole Authorities Standards for Correctional Training Academies Standards for Electronic Monitoring Programs Standards for Food Service Programs Standards for International Correctional Training Academy Standards for Juvenile Community Residential Facilities Standards for Juvenile Correctional Boot Camps Standards for Juvenile Day Treatment Programs Standards for Juvenile Detention Facilities Standards for Juvenile Probation and Aftercare Services Standards for Small Juvenile Detention Facilities

Performance-based standards and expected practices establish clear goals and objectives critical to the provision of constitutional and humane correctional programs and services. The performance-based expected practices include the requirement for practices to promote sound administration and fiscal controls, an adequate physical plant, adherence to legal criteria and provision of basic services. Basic services called for by the performance-based standards and expected practices include the establishment of a functional physical plant, training of staff, adoption of sanitation and safety minimums, and provision of a safe and secure living environment. In offering specific guidelines for facility and program operations, the manuals of performance-based standards and expected practices address due process and discipline, including access to the courts, mail and visitation, searches, and conditions of confinement of special management offenders.

The expected practices are systematically revised to keep pace with the evolution of different correctional practices, case law, and after careful examination of experiences, applying them over a period of time and circumstances. The ACA Standards Committee, which includes membership from the Commission on Accreditation for Corrections, is responsible for expected practices development and revision.

Suggestions and proposals for revisions to the expected practices from the field and interested others are encouraged. The Standards and Accreditation Department has developed an on-line process specifically for this purpose. Proposals should be submitted via the ACA website.

Accreditation Process Descriptions

The American Correctional Association has been the only national body involved in the development of performance-based standards and expected practices for the correctional field. ACA expected practices are supported by ACA's Standards and Accreditation Department and the Commission on Accreditation for Corrections, which is the evaluating and certifying body for accreditation. The department is responsible for the administration of accreditation and ongoing development of correctional expected practices.

The accreditation process is a voluntary program for all types of correctional agencies.

For these agencies, accreditation offers the opportunity to evaluate their operations against international expected practices, to remedy deficiencies, and to upgrade the quality of programs and services. The recognized benefits of such a process include:

improved management; a defense against lawsuits through documentation; demonstration of a "good faith" effort to improve conditions of confinement; increased accountability and enhanced public credibility for administrative and line staff; a safer and more humane environment for personnel and offenders; and the establishment of measurable criteria for upgrading programs, staffing, and physical plant on a continuous basis.

A major component of the accreditation process is the expected practices compliance audit conducted by a visiting committee. The purpose of the audit is to measure operations against the expected practices, based on documentation provided by the agency.

The Visiting Committee Report

The results of the compliance audit are contained in the Visiting Committee report. The finished report consists of a number of sections, which are compiled through an exchange of information between the Visiting Committee, the agency, and Standards and Accreditation Department staff. The report is sent to agency staff for review and distribution to the agency administrator. The completed Visiting Committee report is submitted to the Commission for consideration at the next regularly scheduled panel hearing.

The following information is usually contained in the visiting committee report:

Agency and Audit Narrative– The agency narrative includes a description of program services, a description of physical plant, number of offenders served on the days of the audit, a summary significant incidents and consent decrees, class action lawsuits and/or judgments against the agency/facility, if applicable. The audit narrative, prepared by the visiting committee chairperson, describes audit activities and findings. The narrative examines issues or concerns that may affect the quality of life and services in an agency or facility. Quality of life issues include areas such as staff training, adequacy of medical service, sanitation, use of special management and restrictive housing, reported and/or documented incidences of violence and crowding in institutions, offender activity levels, programming and provision of basic services.

The audit narrative also contains comments as a result of staff and offender interviews, and a detailed explanation of all noncompliant and not applicable expected practices.

Agency Response– The agency has three options for expected practices found in noncompliance: a plan of action; an appeal; or a waiver for the requirement of a plan of action request.

A plan of action is a detailed statement of tasks to be performed in order to achieve compliance with an expected practice found in noncompliance at the time of the audit. The plan of action designates staff responsibilities and timetables for completion.

An appeal is the agency's attempt to change the visiting committee's decision on an expected practice. The result of a successful appeal is a change in the status of the expected practice and a recalculation of the compliance tally.

A waiver may be requested when noncompliance with an expected practice does not adversely affect the life, health, or safety of staff and offenders and when quality of life conditions compensate for the lack of implementation of a plan of action. The granting of a waiver by the Commission waives the requirement for submitting a plan of action; however, it does not change the non-compliant finding.

Auditor’s Response– This section contains the visiting committee's final reply to all responses received from the agency and includes comments regarding the acceptability of plans of action, appeals, and waivers.

Accreditation Hearings

The Commission on Accreditation for Corrections is solely responsible for rendering accreditation decisions and considers an agency’s application at its next regular meeting following completion of the visiting committee report. The Commission is divided into panels that are empowered to reach and render accreditation decisions. These panels hear the individual application for accreditation and include a quorum of at least three Commissioners which includes the panel hearing chairperson. Agencies are notified in writing of the date, time, and location of the hearings by Standards and Accreditation Department Staff.

The panel hearing is the last step in the process. With the panel chairperson presiding, panel members discuss issues and raise questions relative to all aspects of agency operations and participation in the process. The information presented during the hearing and in the visiting committee report is considered by the panel members in rendering accreditation decisions.

The agency must have a representative at the hearing and, in most cases, one or more individuals attend. When special conditions warrant, the visiting committee chairperson or a member of the visiting committee also may be asked to attend the hearings. When this occurs, the auditor provides information to help clarify controversial issues and responds to questions and concerns posed by panel members.

Attendance by any other parties (i.e. media representatives, public officials, or personnel from agencies other than the applicant) occurs only with the permission of the applicant agency. In these cases, the applicant agency representatives and panel members discuss procedures to be followed before commencement of the hearing.

Conduct of Hearings

The panel schedule provides ample time for review of each individual agency pursuing accreditation. Hearings are conducted by the panel chairperson in accordance with established procedures. Panel proceedings require that a formal vote be taken on all final actions, i.e., agency appeals, waiver requests, and the final accreditation decision of the Commission. All panel proceedings are-recorded to assist in preparing minutes of the hearings. Panel activities generally occur as follows:

• Applicant agency representatives are requested by Standards and Accreditation Department staff to be on-call to allow for scheduling flexibility.

• A designated waiting area is usually provided for this purpose.

• When the panel is ready to review the agency, the Standards and Accreditation Department staff representative notifies agency representative(s).

• The hearing opens with an introduction by the panel chairperson.

• The agency representative is asked to give a brief description of the program.

• If a Visiting Committee member is present at the hearing, the panel chairperson may request that the auditor present an account of the visit, focusing on matters particularly pertinent to the decision or specific panel actions. In some cases, however, the panel may wish to call on the Visiting Committee member only to request additional information at different points during the hearing.

• The panel chairperson leads review of each individual non-compliance finding.

The agency representative presents information relative to their requests for waivers, plans of action, and appeals. The agency may also present additional materials, including photographs or documentation, for review by the panel.

• Following the agency presentation, the chairperson has the option of calling the panel into executive session to consider the information provided, determine findings, and make an accreditation decision. Whether or not panel deliberations occur in the presence of agency personnel or in executive session, varies from panel to panel, considering the preference of panel members and the sensitivity of issues to be discussed regarding the application.

In final deliberations, the Commission panel:

• Ensures compliance with all mandatory expected practices and at least 90 percent of all other expected practices

• Responds with a formal vote to all appeals submitted by the applicant agency

• Responds with a formal vote to all requests for waivers, and plans of action submitted by the applicant agency

At this time, the panel also:

• Assures that an acceptable plan of action will be submitted for every non-compliance finding, including those for which appeals of non-compliance and waiver requests have been denied by the panel. In judging the acceptability of plans of action, the panel ensures that all of the information requested on the form is provided.

Furthermore, the feasibility of plans to achieve compliance is considered, including specific tasks, time frames, and resource availability (staff and funding) for implementing proposed remedies.

• Addresses to its satisfaction any concerns it has with Visiting Committee comments about the quality of life in the facility or program, patterns of non-compliance, or any other conditions reviewed by the panel relating to the life, health, and safety of residents and staff

• For each application, a roll call vote to award accreditation, extend an agency in Candidate or Correspondent Status, or deny accreditation is conducted. The options for final action available to the panel are outlined in the next section.

• If the panel has deliberated in executive session, agency representatives are invited back into the meeting and informed of the panel’s final decision and actions or recommendations on all other issues raised by the applicant. If accreditation has not been granted, the chairperson discusses with agency personnel specific reasons for the decision and the conditions of extension in Candidate or Correspondent Status and procedures for appeal.

Accreditation Decisions

The decisions available to the Commission panel relating to the accreditation of an agency are:

• Three-year accreditation award based on sufficient compliance with expected practices, acceptance of adequate plans of action for all applicable non-compliant findings, (or approval of the Waivers of the requirement that a plan of action be submitted) and satisfaction of any other life, health, and safety conditions established by the panel.

• Extension of the applicant agency in initial accreditation process (initial accreditation only) for reasons of insufficient compliance, inadequate Plans of Action, or failure to meet other requirements as determined by the panel, the Commission may stipulate additional requirements for accreditation if, in its opinion, conditions exist in the facility or program that adversely affect the life, health, or safety of the offenders or staff. Extension of an agency is for a period of time specified by the panel and for identified deficiencies if in the panel's judgment, the agency is actively pursuing compliance.

• Continuation of accreditation in Probationary Status after reaccreditation hearings is considered when the panel specifies that compliance levels are marginal, there is a significant decrease in compliance from the previous audit (in the case of reaccreditation), or there are quality of life issues that would indicate continued monitoring. Probationary Status lasts for a specific period of time designated by the Commission to allow for correction of deficiencies. While an award of accreditation is granted, a monitoring visit must be completed, and the report presented at the next meeting of the Commission. At the end of the probationary status, another monitoring visit may be conducted to ensure that the deficiencies have been corrected. Following the visit, a report is prepared for review by the Commission at its next regularly scheduled meeting. The Commission again reviews the program and considers removing the probationary status or the revocation of accreditation.

When the agency corrects the deficiencies within the probationary status period and the corrections have been verified and accepted by the Commission on Accreditation of Corrections, the agency resumes its status as an accredited agency.

• Denial of accreditation denies initial accreditation or removes the agency from Accredited Status (in the case of reaccreditation) and withdraws the agency from the accreditation program. Situations such as insufficient compliance, inadequate plans of action, failure to meet other requirements as determined by the panel or quality of life issues may lead to the denial of accreditation. If an agency is denied accreditation by the panel, it may be immediately appealed to the full commission. If the agency is denied accreditation by the full commission, it is withdrawn from the process and is not eligible to re-apply (as an applicant) for accreditation status for a minimum of six months from the date of that panel hearing.

The agency receives written notification of all decisions relative to accreditation after the hearing.

Appeal Process

The accreditation process includes an appeal procedure to ensure the equity, fairness, and reliability of its decisions, particularly those that constitute either denial or withdrawal of Accredited Status, or placement into probationary status. Therefore, if an agency is denied accreditation, it may be immediately appealed to the full commission.

If an agency is put in probationary status by the panel, it may submit an appeal of the placement into probationary status. The basis for reconsideration of probationary status is based on grounds that the decision(s) were:

• A misinterpretation of the criteria and/or procedures promulgated by the Commission.

• Based on incorrect facts or an incorrect interpretation of facts.

• Unsupported by substantial evidence.

• Based on information that is no longer accurate.

• The reasonableness of the expected practices, criteria, and/or procedures for the process may not serve as the basis for reconsideration.

The procedures for reconsideration are as follows:

• The agency can submit a verbal appeal immediately to the Director of Standards and Accreditation or a written request for reconsideration within 30 days of the adverse decision stating the basis for the request.

• The Executive Committee of the Commission, composed of the officers of the Commission, reviews the request and decides whether or not the agency’s request presents sufficient evidence to warrant a reconsideration hearing before the Commission. The agency is notified in writing of the Executive Committee’s decision.

• If the decision is made to conduct a hearing, the hearing is scheduled for as soon as possible if the appeal is made verbally or if in writing, for the next full Commission meeting and the agency is notified of the date.

• The agency, at its option and expense, has the right of representation, including counsel.

• Following the hearing held before the Commission, the decision, reflecting a majority opinion, is made known to the agency immediately.

• Pending completion of the reconsideration process, the agency maintains its prior status.

• Until a final decision has been reached, all public statements concerning the agency’s accredited status are withheld.

Accredited Status

The accreditation period is three years, during which time the agency must maintain the level of compliance achieved during the audit and work towards compliance of those expected practices found in non-compliance. Regular contact with Standards and Accreditation Department staff should also be maintained. The Annual Report, Critical Incident Report and Significant Incident Summary forms discussed below are available on the ACA website at www.aca.org or through your Accreditation Specialist.

Annual Report

During the three year accreditation period, the agency submits an annual report to the Standards and Accreditation Department. This report is due on the anniversary of the last audit date utilizing the template provided by ACA staff (also available at www.aca.org).

It contains the following information:

Current Compliance Levels - This includes any changes in compliance since accreditation, listing on a case by case basis any expected practice with which the agency has fallen out of compliance or achieved compliance.

Update of Plans of Action - A progress report is included with respect to plans of action submitted to the hearing panel, indicating the status of the completion of the plans. potential revision to plans reflecting the need to request additional time, funds, and/or resources to achieve compliance should also be included.

Significant Incident Report Summary - A report is made of events and occurrences at the agency during the preceding year that impact on compliance, agency operation, or the quality of services provided by the agency.

Standards and Accreditation Department staff review the annual report received from the agency and respond to clarify issues or request additional information if necessary.

Critical Incident Report

In addition to submission of the annual report, the agency is responsible for notifying Standards and Accreditation Department staff of any critical incident that has the potential to affect compliance or facility accreditation as soon as possible within the context of the event itself. This information is to be submitted to ACA as soon as possible within the context of the incident itself, using the Critical Incident Report template available at www.aca.org.

http://www.aca.org/ http://www.aca.org/ http://www.aca.org/

Performance Monitoring Visit

A Performance Monitoring Visit will occur between 14-24 months following an ACA audit (reaccreditation or initial). It is scheduled with limited notice to the facility. Visits will be conducted by an ACA auditor or ACA staff over one or two days depending on facility size and population. A visit will start with guidance by an ACA staff member to the auditor on what will be reviewed during the visit based on the last ACA audit, panel minutes from the Commission hearing, annual reports, critical incident reports and letters addressed to ACA. The assigned auditors will receive these documents from the assigned ACA staff members.

The schedule included an entrance interview, a partial tour of the facility, review of some current ACA files identified by ACA to ensure accreditation is being maintained, review of the current Significant Incident Summary and Outcome Measures, interviews of staff and offenders (clients, etc.) and an exit interview.

The auditor will also be looking at any plans of action for non-compliance of expected practices from their last audit. They will check if the plan of action has brought it into compliance; and if not, they will ask for a status update and what issues there are.

The auditor will then write a report for the Director of Standards and Accreditation to review and if needed send it to the Commission. All ACA accredited organizations and facilities will go through this process since it is written in all new contracts.

Monitoring Visits

Monitoring visits to agencies in Accredited Status are conducted by an ACA auditor(s) or staff in order to assess continuing compliance. A monitoring visit may be conducted at any time during the accreditation period with notice to the agency. The determination of need for a monitoring visit is based on:

• Compliance levels, findings, and recommendations by the Commission on

Accreditation for Corrections during the hearing.

• Incidents or events reported by the agency in its annual report.

• Problems indicated by adverse media reports or correspondence received by Standards and Accreditation Department staff, disturbances at the agency, or special investigations.

The length of the visit varies depending on the number of expected practices or special issues that must be addressed during the visit. The visits are conducted similar to expected practice compliance audits, but on a reduced scale. Monitoring visits are charged to the agency at a rate of cost plus twenty-five percent or as stipulated in the contract.

Activities, as a general rule, involve a review of selected mandatory expected practices, all expected practices found in non-compliance at the time of accreditation, and any other concerns identified by the Commission. The visit also involves a tour of the agency and interviews with staff and offenders to ensure maintenance of the requirements of accreditation. It concludes with an exit interview during which the auditor informs the agency staff of the findings of the visit.

Following the visit, the auditor prepares a monitoring visit report that addresses findings of the visit. The report includes a list of expected reviewed, explanation of noncompliance findings, results of the tour and interviews with agency staff and offenders, and discussion of any issues believed to be relevant to the agency’s accreditation. The report, as with others prepared by auditors, is reviewed and sent to the agency by Standards and Accreditation Department staff.

When a monitoring visit to the agency reveals deficiencies in maintaining compliance levels that existed at the time of accreditation, the agency prepares a response providing explanation of the problems indicated in the report. The monitoring visit report and the agency response are submitted to the Commission for review during a regular hearing. Agency representatives are advised of the date, time, and location of the review, and must attend. At the discretion of the Commission, the agency may be placed in probationary status and a revisit conducted to determine if deficiencies have been corrected.

Revocation of Accreditation

If the Commission panel believes that an agency’s failure to maintain continuous compliance with certain expected practices is detrimental to life, health, and safety of residents and staff, the Commission may place an agency on probation. Probationary status last for a specific period of time designated by the Commission at its next regularly schedule meeting. The Commission again reviews the program and considers removing the probationary status or revoking accreditation. When the agency corrects the deficiencies within the probationary status period and the corrections have been verified and accepted, the agency resumes its status as an accredited agency. An agency that does not satisfactorily correct the deficiencies may be withdrawn from accreditation.

Another condition that may result in a rehearing and consideration of revocation is following a significant event in an agency (i.e. major disturbance, death from other than natural causes or allegations of physical/sexual abuse of offenders). Failure to notify the Standards and Accreditation Department in a timely manner may result in suspension of the agency’s accreditation. Once ACA is notified of the major event, the Director of Standards and Accreditation may consult with the Executive Committee of the Commission, who may request a monitoring visit. If a visit is warranted, ACA will notify the agency and a date will be established with the concurrence of the facility. The monitoring visit will take place within 14 days of this notification. The monitoring visit report will be sent to the Director of Standards and Accreditation within 7 days of the monitoring visit and then forwarded to the Executive Committee of the Commission. Following review of the report, a determination will be made by the Executive Committee as to whether revocation of accreditation is warranted. Prior to any rehearing, agency representatives will be notified, so that any issues may be addressed and responded to in writing.

Accreditation is revoked for the following reasons:

• Failure on the part of the…