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Accreditation Procedure for Credentialing Programs

PUBLIC PROCEDURE CRED-PR-501 Issued: 2022-3-23, Revision: 1

References ANAB-AG-1008: Terms and Conditions for Accreditation
ANAB-MA-1002: ANAB Systems Integrity Manual
ANAB-MN-100: ANAB Systems Integrity Manual
ANAB-PR-1017: Impartiality Policy
ANAB-PR-1026: Nonconformity Challenge Procedure
ANAB-PR-1028: Procedure for Taking Actions Pursuant to AG 1008/AG 1008-G: Fraud, Concealment, False Information, and Intentional Violation of Accreditation Requirements
CFP-PL-802: Manual of Operations: ANSI-CFP Accreditation Program For Certifiers Of Food Protection Managers
CRED-PR-033: Competence Procedure - Assessors
CRED-PR-502: Operating Procedure for Credentialing Accreditation Committees
CRED-PR-520: Procedure for Remote Assessments
CRED-PR-522: Fees - Accreditation of Credentialing Programs
CRED-PR-545: Assessor Manual for Credentialing
CRED-PR-575: Risk Analysis Procedure of the Accreditation Process for Credentialing Bodies
Conference for Food Protection- Standards for Accreditation of Food Protection Manager Certification Programs
ASTM D8403-21, Standard Practice for Certificate Programs within the Cannabis and Hemp Industries
ASTM E2659: Standard Practice for Certificate Programs
ISO 9000, Quality management systems - Fundamentals and vocabulary
ISO/IEC 17000, Conformity assessment - Vocabulary and general principles
ISO/IEC 17011, Conformity assessment - General requirements for accreditation bodies accrediting conformity assessment bodies
ISO/IEC 17024, Conformity assessment - General requirements for bodies operating certification of persons
Contents
1Objective
1.1This document serves as the overarching procedure for the accreditation of credentialing programs to include ISO/IEC 17024, ASTM E2659, ASTM D8403, and Conference for Food Protection Manager by the ANSI National Accreditation Board (ANAB) (herein after referred as "The Program").
2Definitions
2.1The definitions in ISO/IEC 17000, ISO/IEC 17011, and ISO 9000 apply.
2.2Conformity Assessment Body (CAB): Bodies operating certification of persons under the ISO/IEC 17024 standard or the Conference for Food Protection Accreditation Standard and Certificate Issuer under the ASTM E2659 standard or the ASTM D8403 standard.
2.3Accreditation Decision (ISO/IEC 17011 3.13): a decision on granting, maintaining, extending, reducing, suspending, and withdrawing accreditation.
2.4Accreditation Committee: The group of people authorized by an ANAB business unit to make accreditation decisions relating to a specific accreditation standard, which are subject to appeal. The roles of the accreditation committees are defined in CRED-PR-502 (17024, ASTM E2659, ASTM D8403 programs) and CFP-PL-802 (CFP program).
2.4.1Personnel Certification Accreditation Committee (PCAC): The committee responsible for all accreditation decisions related to initial, reaccreditation, and surveillance except in cases where there are no nonconformities for the ISO/IEC 17024 program.
2.4.2Certificate Accreditation Program Accreditation Committee (CAPAC): The committee responsible for all decisions related to initial, reaccreditation, and surveillance except in cases where there are no nonconformities for the ASTM E2659 or ASTM D8403 programs.
2.4.3ANAB-CFP Accreditation Committee (ACAC): The committee responsible for all decisions related to initial, reaccreditation, and surveillance except in cases where there are no nonconformities for the Conference for Food Protection program.
2.5Evaluation Task Group (ETG): An ad-hoc group of two or more members appointed by the program director or program manager from an accreditation committee for the purpose of conducting a detailed review of an assessment and recommending a decision to the accreditation committee. The specific roles of the ETG are defined in CRED-PR-502 and CFP-PL-802.
2.6Nonconformity: The non-fulfillment of a requirement (ISO 9000 3.6.9). A nonconformity is not an accreditation decision. A nonconformity can be challenged as per ANAB-PR-1026 Nonconformity Challenge Procedure.
2.7Appeal (ISO/IEC 17011 3.21): A request by a CAB for reconsideration of any adverse accreditation decision. An accreditation decision can be appealed as per ANAB's Appeal Procedure.
2.8Opportunity for Improvement: A statement that describes requirements that could be more effectively addressed through enhanced process or illustrated results. An OFI denotes compliance and not necessarily a basis for a nonconformity if ignored. Opportunities for improvements shall not provide consultancy.
2.9Accreditation Cycle: Begins at the initial accreditation date and expires five years later, during which time surveillance assessments are conducted annually (at a minimum). In the last year of the cycle, a reaccreditation assessment is conducted prior to expiration.
3General Provisions
3.1ANAB has established this procedure to govern the accreditation of its credentialing programs as per ISO/IEC 17011 thereby creating stakeholder confidence in its accreditation. This procedure has been developed in accordance with ANAB Systems Integrity Manual ANAB-MA-1002 provision 7.4 to govern the accreditation of credentialing programs.
3.2The requirements, assessments, and decisions on accreditation of CABs shall be confined to those matters specifically related to that set forth in the standard under which the accreditation is sought and other Program requirements and /or regulations.
3.3The accreditation committees (PCAC, CAPAC, and ACAC) are established as per ANAB-MA-1002 provision 7.4. The governance, functions, and actions of the accreditation committee are defined in CRED-PR-502 (17024, ASTM E2659, ASTM D8403 programs) and CFP-PL-802 (CFP program). ANAB shall ensure that the members of the accreditation committee or other individuals involved in this process abide by ANAB's Impartiality Policy ANAB-PR-1017.
3.4ANAB shall make public the accreditation status of a CAB including information on suspension or withdrawal of accreditation.
3.5The Program is subject to such provisions as organizational structure, legal responsibility, impartiality, confidentiality, conflict of interest, liability, financing, modification of accreditation activity and related requirements, as well as the management system stipulated in ANAB Systems Integrity Manual ANAB-MA-1002.
3.6All changes to this policy document must be approved by ANAB Credentialing SBU leader.
4Informational Visit
4.1If an informational visit is conducted before the initial assessment, the Program staff shall select a qualified assessor and coordinate arrangements for the visit. The informational visit shall be conducted with the agreement of the CAB.
4.2The purpose of an informational visit is to clarify issues arising from the accreditation requirements. The duration of the informational visit should typically not exceed more than one day. During the information visit an assessor shall not engage in any consultancy.
5Preliminary Application
5.1A CAB interested in obtaining accreditation must submit a preliminary application available on the web or by request. The form must be submitted by the duly authorized CAB representative and provide evidence to demonstrate compliance with program specific eligibility requirements.
5.2If the preliminary applicant does not meet the eligibility requirements, the applicant may submit further documentation within 90 days of receipt of written notification. Otherwise, the preliminary application is automatically rejected. If a CAB's preliminary application is rejected, it may resubmit a new preliminary application after making required changes to meet the eligibility requirements.
5.3Approved preliminary applicants shall be required to submit a complete initial application within 12 months of the date of preliminary approval. If a preliminary applicant has not submitted a complete application within the specified timeframe, a new preliminary application and a new application fee is required.
6Application for Accreditation
6.1A complete initial application for accreditation shall be made by a duly authorized representative of the applicant CAB. The application, supporting documents, and correspondences shall be in English and submitted electronically. The applicant must abide by the Terms and Conditions for Accreditation (AG 1008) which becomes effective on the date a client submits an application for accreditation. AG 1008 is publicly available on www.anab.org.
6.2The applicant CAB must pay the application fee as per CRED-PR-522 before ANAB commences the initial application review.
6.3The initial application must include the following:
a)CAB name, legal entity type, address(es) and human and technical resources;
b)CAB relationship to a larger entity if any, and, information on activities conducted at all locations including virtual site(s);
c)Accreditation scope, including limits of capability where applicable and identifying at least the following: (1) the type of certification (e.g., persons, certificate issuer, CFP); (2) certification scheme(s); (3) the standards, normative documents and/or regulatory requirements to which persons are certified, as applicable; and/or (4) industry sectors (where relevant);
d)a commitment to continually fulfil the requirements for accreditation and and the Terms and Conditions of Accreditation (AG 1008).
6.4Program staff shall review the application to determine the suitability of the application to initiate an assessment.
6.5The Program staff shall conduct a review of the program capability to carry out the assessment in terms of ANAB's own policies and procedures and considering availability of competent assessors and decision makers. The review shall also include ability to conduct the assessment in a timely manner. In situations where assessments cannot be conducted in a timely manner, the CAB shall be notified.
6.6Program staff may request additional information and/or clarification from the applicant. A response to a request for additional information must be received within 90 days of the request; otherwise, the application may be considered withdrawn and the CAB may be required to start the application process from the beginning by submitting a new preliminary application.
7Document Review
7.1The program staff shall select an assessment team based on absence of conflict of interest and program-specific competence criteria.
7.2The CAB shall be provided with the resumes of the proposed members of the assessment team. Based on conflict of interest, the applicant may object to the named assessor(s) in writing with sufficient justification within 10 days from receipt of the proposed assessment team. Assessor objections will be reviewed on a case by case basis by program staff in consultation with the program director, if needed.
7.3If no objection is received, the assessment team shall be considered approved. All selected assessors must have signed the ANAB Independent Contractor Agreement ANAB-AG-1007.
7.4The assessment team shall review the application and accompanying documentation for conformity with applicable standard (e.g., ISO/IEC 17024, ASTM E2659, ASTM D8403, or CFP) and program requirements. The lead assessor conducts the review with input from the other assessor(s).
7.5If additional documentation is required by assessors, the applicant must provide it within 90 days of the request. Otherwise the application shall be considered withdrawn and the CAB may be required to start the application process from the beginning by submitting a new preliminary application.
7.6At any point in the application or initial assessment process, if there is evidence of fraudulent behavior or a CAB intentionally provides false information or conceals information, the application shall be rejected or assessment process terminated.
8Onsite Assessment
8.1ANAB may not proceed with further assessment based on the document review. In such cases, the results with their justification shall be communicated to the CAB in writing.
8.2The assessment team shall assess the competence of the CAB to perform all activities in its scope of accreditation as per the assessment techniques and principles of assessments described in Assessor Manual for Credentialing (CRED-PR-545).
8.3The assessment team shall assess the performance of a sample of the CAB activities as per the sampling procedures described in Assessor Manual for Credentialing (CRED-PR-545) considering the risk associated with the activities, locations, and personnel as per Risk Procedure CRED-PR-575.
8.4Upon completion of the document review, the lead assessor shall arrange a schedule for the onsite assessment.
8.5Assessors in conjunction with the applicant and program staff shall develop an assessment plan. The plan shall include:
a)dates and expected length of onsite assessment;
b)tentative schedule for the assessment;
c)locations and activities that will be assessed;
d)personnel to be assessed where applicable;
e)assessment techniques;
f)witnessing of an exam, if applicable (e.g., practical exam or remotely proctored exam).
8.6Any disagreement between the assessors and the applicant regarding the assessment plan shall be reviewed by the program staff and if necessary by the program director.
8.7The onsite assessment shall begin with an opening meeting during which the purpose of the assessment and accreditation requirements are clearly defined and assessment plan and scope confirmed.
8.8The assessors shall witness a practical examination and remote proctoring test administration where relevant. Assessors may witness other forms of test administration where relevant.
8.9The assessment team shall refer back to ANAB staff if clarification is needed.
8.10The assessment team shall analyze all relevant information and evidence gathered during the document review as well as the onsite assessments. The analysis shall be sufficient to allow the assessment team to determine the extent of fulfillment of accreditation requirements, including conformance to the applicant's own policies and procedures.
8.11At the conclusion of the assessment, the assessment team shall hold a closing meeting with the CAB. At the closing meeting the assessment team shall present its findings and detail in writing any nonconformities. The CAB shall be provided an opportunity to seek clarification on the findings including the nonconformities.
8.12Opportunities for improvements do not require a response.
8.13A CAB may dispute a non-conformity as per the Nonconformity Challenge Procedure ANAB-PR-1026.
8.14Within 15 business days of the closing meeting, the lead assessor is responsible for preparing and submitting an assessment report covering all of the assessment activities. After staff review, the report is made available to the CAB. ANAB shall bear ultimate responsibility for the assessment report.
8.15The report will contain the following information to support the conclusion arising from the assessment:
a)personnel interviewed;
b)scope/s assessed;
c)evidence for conformance; and
d)nonconformities/opportunities for improvement identified, if any.
8.16If the report on the outcome of the assessment differs from the outcome delivered at the close of the assessment, the program staff shall provide an explanation to the assessed CAB in writing.
8.17When nonconformities are finalized in ANSICA, a CAB must complete a root cause analysis and submit corrective action or a corrective action plan within 90 days. In addition, a CAB must provide implementation target dates to resolve the nonconformities. The responses to the nonconformities are reviewed by the assessors to determine if the actions are sufficient and appropriate. The assessors shall request additional information if the CAB responses are not sufficient. ANAB may conduct a follow-up assessment to verify effective implementation of corrective actions or require evidence of effective implementation.
8.18A CAB has 180 days from the date the nonconformities are finalized in ANSICA to close all of the nonconformities. The accreditation committee or the program director may grant up to an additional 90 days to close the nonconformities based on satisfactory progress made by the CAB to correct them. Any further extension is based on satisfactory progress in closing the nonconformities. The accreditation committee may vote to deny accreditation if the nonconformities are not closed within the prescribed timeframe. Even when the decision is denial of accreditation, all assessment fees must be paid.
8.19If accreditation is not granted, the CAB shall be notified of its further options including its right to appeal the accreditation decision. Appeals against an accreditation decision shall be processed in accordance with ANAB appeal procedure.
8.20The Program does not outsource any assessment activities.
9Decision on Accreditation
9.1The recommendation of the ETG shall be reviewed by the accreditation committee barring those members that have conflict of interest with the CAB. The accreditation committee shall be provided the following information:
a)unique identification of the CAB;
b)date(s) and type(s) of assessment(s) (e.g. initial, reassessment);
c)name(s) of the assessor(s) and, if applicable, technical expert(s) involved in the assessment;
d)unique identification of all locations assessed;
e)scope of accreditation that was assessed;
f)the assessment report(s);
g)a statement on the adequacy of the organization and procedures of the CAB in fulfilment of accreditation requirements;
h)sufficient information to demonstrate the satisfactory response to all nonconformities;
i)where relevant, any further information that may assist in determining the competence of the CAB as determined through conformity with requirements; and
j)where appropriate, a recommendation as to the accreditation decision for the proposed scope.
9.2The accreditation committee shall vote without undue delay on accreditation in accordance with CRED-PR-502 or CFP-PL-802. Accreditation shall be granted after all the nonconformities are closed and the CAB has demonstrated compliance with the standard and program requirements.
9.3The effective date of accreditation shall be the day of the accreditation decision by the accreditation committee. If accreditation is granted, the program staff without delay shall send an accreditation certificate that lists the following:
a)ANAB logo and name of ANAB as the accreditation body;
b)CAB name and name of the applicable legal entity if different;
c)Address of the CAB;
d)Accredited scopes;
e)Unique accreditation ID of the accredited CAB;
f)the effective and expiry date of the accreditation;
g)a statement of conformity to the standard including issue or revision.
9.4ANAB may withhold accreditation action until the CAB has paid all outstanding invoices to ANAB.
9.5If accreditation is not granted, the CAB shall be notified of its further options including its right to appeal the accreditation decision. Appeals against an accreditation decision shall be processed in accordance with ANAB appeal procedure.
10Surveillance Assessment
10.1Surveillance assessment activities shall commence no later than 12 months from the date of initial accreditation as indicated on the ANAB certificate of accreditation. The purpose of these activities shall be to:
a)determine that the program continues to operate in conformance with ANAB requirements and the requirements of the applicable standard (e.g. ISO/IEC 17024, ASTM E2659, ASTM D8403, CFP);
b)determine that the program continues to operate as described in the documentation governing the program; and
c)determine if any major changes reported have affected the conformity of the program to the standard or accreditation requirements.
10.2Surveillance accreditation activities shall include but not be limited to:
a)assessments needed to confirm that the program is in conformance as set forth in the program documents approved by ANAB and in accordance with ANAB requirements;
b)submission of an annual surveillance self-assessment report.
10.3The CAB shall submit an annual surveillance self-assessment report on a date to be determined by the program staff. The submission is typically due 90 days before the anniversary of initial accreditation granted date. The CAB can request an extension that is subject to approval by the program director.
10.4Failure to submit a complete annual surveillance self-assessment report may result in ANAB administrative action or accreditation action, including probation, suspension or withdrawal of accreditation.
10.5The program staff shall review the report for completeness and, if necessary, request clarification or additional information from the CAB. Additional information must be submitted within 14 days of the request.
10.6The assessment team that conducts the initial assessment conducts the surveillance assessments over the course of the accreditation cycle. If there is any change in the assessment team, the CAB shall have the opportunity to approve or reject the new members of the assessment team based on conflict of interest.
10.7After staff review, the surveillance self-assessment report is sent to the assessment team for document review. If the assessors request additional information, it must be submitted within 30 days of the request.
10.8During the first and third year after the year in which the CAB was accredited or reaccredited, ANAB shall conduct an onsite assessment in addition to the document review. During other years, surveillance shall be limited to document review unless ANAB determines that an unscheduled onsite assessment is necessary in order to ascertain compliance with the standard and/or program requirements.
10.9ANAB requires the CAB to propose the corrective action plan and a target implementation date for all nonconformities identified during surveillance and reassessment. All nonconformities must be closed within 90 days of being finalized in ANSICA. The accreditation committee or the program director may grant up to an additional 90 days to close the nonconformities based on satisfactory progress made by the CAB to correct them. Any further extension is based on satisfactory progress in closing a nonconformity.
10.10If a non-conformity is not closed within the specified time period, the accreditation committee shall vote to place the CAB on probation, or suspend or withdraw accreditation.
10.11Sampling as defined in the program procedure CRED-PR-545 (annex) shall ensure proper evaluation of the competence of the CAB.
10.12The assessment plan shall take into consideration risk associated with the accredited scopes as per CRED-PR-575.
10.13Within 15 business days of the completion of surveillance, the lead assessor is responsible for preparing and submitting an assessment report covering all of the assessment activities. After staff review, the report is made available to the CAB. ANAB shall bear ultimate responsibility for the assessment report.
10.14A surveillance report, including the implemented corrective actions or the proposed plan for their implementation by the CAB, is reviewed by the ETG. The ETG in turn makes recommendation to the accreditation committee which makes decision in accordance with CRED-PR-502.
10.15The accreditation committee shall vote to grant continued accreditation after all the non-conformities have been closed and the CAB has demonstrated compliance with the standard and program requirements.
10.16In those cases where no nonconformity is identified during the annual surveillance, the program director is authorized to grant continued accreditation after reviewing the assessment report.
10.17Based on the recommendation of the ETG, the accreditation committee may vote to lift the suspension after the CAB closes all the non-conformities and demonstrates compliance to the standard and program requirements.
10.18Accredited CABs shall be assessed an annual fee in accordance with the Program fee schedule (CRED-PR-522).
11Extraordinary Assessment
11.1ANAB may conduct extraordinary assessment(s) of accredited CABs for the following reasons:
a)significant organizational changes;
b)request for scope extension;
c)severity and / or multitude of nonconformities identified during previous assessments;
d)complaints received against the CAB;
e)relationships that cause real or perceived conflicts of interest; and
f)other conditions deemed appropriate by the Credentialing SBU leader.
12Reassessment
12.1All accredited CABs shall undergo reassessment every five years. The reassessment shall be planned and conducted before the end of the accreditation cycle. All the requirements in the standard for all the accredited scopes shall be covered during the reassessment. Reaccreditation applications are due no later than three months prior to the expiration date of the current accreditation term.
12.2The reassessment process follows the application and initial assessment process almost entirely with the following exceptions:
a)no preliminary application stage is required;
b)no application fee is due; and
c)the assessment team shall consider the information gathered/findings from previous assessments over the accreditation cycle.
12.3All nonconformities identified during the reassessment must be closed within 90 days of being finalized in ANSICA. The accreditation committee or the program director may grant up to an additional 90 days to close the nonconformities based on satisfactory progress made by the CAB to correct them. Any further extension is based on satisfactory progress in closing a nonconformity.
12.4If a nonconformity is not closed within the specified time period, the accreditation committee shall vote to place the CAB on probation, or suspend or withdraw accreditation.
12.5Based on the recommendation of the ETG, the accreditation committee may vote to lift the suspension after the CAB closes all the non-conformities and demonstrates compliance to the standard and program requirements.
12.6If the accreditation certificate expires prior to accreditation committee decision on the renewal of accreditation and the reassessment process is in progress, the program director shall extend the validity by 90 days. The program staff shall issue a new certificate of accreditation reflecting the 90 day extension. Any further extension will require a vote by the accreditation committee. Upon reaccreditation, the CAB shall be issued a new certificate of accreditation based upon the original effective date of granting accreditation, regardless of any extension(s).
13Extension and Reduction of Scope of Accreditation
13.1A CAB may apply for additional scopes for accreditation by completing a scope extension application at any time during the year. A CAB may also submit additional scope/s for accreditation as part of the reassessment application, in such a situation a separate scope extension application is not required. All information pertaining to the new scope/s and accredited scopes must be included with the reaccreditation application.
13.2A scope extension assessment must include a document review and, if necessary, an onsite assessment and witnessing to confirm the new scope/s meet the standard and program requirements.
13.3A CAB must pay the scope extension fee as documented in the fee procedure CRED-PR-522 along with submission of new scopes for accreditation.
13.4The scope extension assessment shall take into consideration the risk associated with the activities or locations to be covered in the scope extension as per CRED-PR-575 taking into account appropriate assessment techniques as defined in CRED-PR-545.
13.5A nonconformity identified during a scope extension assessment may apply to all accredited scopes. A CAB has 180 days from the date of the nonconformities being finalized in ANSICA to close any nonconformities identified during a scope extension assessment.
13.6The decision on a scope extension shall be made by the relevant accreditation committee in accordance with the Program procedures after all nonconformities related to the new scopes are closed and the CAB has paid all the fees related to scope extension.
13.7All subsequent assessments (surveillance and reassessment) shall include review of all the accredited scopes.
13.8The accreditation committee may vote to reduce the scope of accreditation of a CAB if an accredited scope does not conform to the standard or program requirements.
13.9An accredited CAB may choose to voluntarily request reduction in the scope of its accreditation at any time by submitting a written notice to the program staff.
13.10The accreditation committee shall vote to withdraw ANAB accreditation from a CAB if any of the following occurs:
a)filing of any voluntary or involuntary petition of bankruptcy;
b)liquidation of the business or the organization;
c)discontinuance of the accredited program;
d)CAB's failure to correct a nonconformity;
e)uncorrected misuse of the ANAB accreditation symbol;
f)where there is evidence of fraudulent behavior, or the CAB has intentionally provided false information or concealed information; or
g)failure to comply with ANAB policies and procedures, including the failure to pay the accreditation fees.
13.11If at any time an accredited CAB defaults in any way on its obligations to ANAB as per AG-1008 Terms and Conditions for Accreditation, the program staff shall call this administrative infraction to the attention of the organization for immediate correction. Communication to the CAB shall include a notice that if the administrative matter is not corrected within a specified timeframe, the SBU leader shall place the organization on probation or suspension or withdraw accreditation. PR 1028 Procedure for Taking Actions Pursuant to AG 1008/AG 1008-G will be followed as applicable.
13.12An accredited CAB has the right to voluntarily withdraw its accreditation, in whole or in part, at any time for any reason. Request for withdrawal must be submitted in writing by an authorized representative of the organization.
13.13An annual fee is payable by the CAB for the year in which the accreditation is withdrawn.
13.14When ANAB accreditation is withdrawn (including voluntary withdrawal) or suspended, the program staff shall update the accreditation directory accordingly.
13.15Upon withdrawal or suspension of its accreditation, a CAB must discontinue use of the ANAB accreditation symbol, all advertising material which references ANAB accreditation and return any accreditation documents deemed appropriate including its accreditation certificate to ANAB.

Recognitions