Section 50. On-site audit procedures

A. The certification analyst shall, on the first day of the audit, orient the team to the audit process and afford the facility or program administrator an opportunity to brief the team on aspects of the facility or program that may have a bearing on the audit.

B. The facility or program administrator shall grant the team access to all documents, staff and areas of the facility or program that are relevant to establishing compliance.

C. A facility or community residential program with an approved variance shall provide such documentation to the certification team.

D. Data shall be collected through documentation, interview and observation.

E. The certification analyst shall brief the facility or program administrator daily on audit progress and preliminary findings. At this time, the facility or program administrator may introduce additional data having a bearing on the team's findings.

F. The entire certification team shall be included in compliance decisions.

1. When a team member finds an indication of noncompliance, the team member shall notify the entire team and provide all available information regarding the standard in question.

2. The team leader shall obtain consensus of the members to the compliance.

3. If a consensus cannot be obtained, the matter shall be referred to the Compliance and Accreditation Unit supervisor.

G. The team shall hold a final debriefing with the facility or program administrator to discuss the team's compliance audit findings.

H. At the request of the facility or program administrator, the certification team shall report compliance audit findings to facility or program staff.

Historical Notes

Derived from VR230-01-003:1 § 2.3, eff. May 1, 1993; amended, Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 06, eff. December 21, 2011.

Statutory Authority

§ 53.1-5 of the Code of Virginia.