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Conditions for Granting, Maintaining, Extending, Reducing, Suspending or Placing on Probation and Withdrawing Accreditation

PUBLIC PROCEDURE CAP-PR-319 Issued: 2017-5-18, Revision: 1

References ANSI-PR-004: Appeals
CAP-PR-315: Application and Initial Assessment Process
ASTM E2659-09, Standard Practice for Certificate Programs
1.1Objective of this procedure is to document the process of granting of initial accreditation as well as maintaining, extending, reducing, suspending and withdrawing accreditation by CAPAC for the certificate issuer.
3The Initial Decision on Accreditation
3.1The CAPAC Evaluation Task Group (ETG) is a 2-3 -member group composed of CAPAC members. The ETG is responsible for reviewing the assessment report to ensure the assessors’ findings on non-conformities are substantiated. If there is a concern with the findings, a consensus will be reached among the assessors and ETG. If a consensus cannot be reach, the issue will be presented to the full CAPAC for their final decision. The ETG recommends the accreditation action to the CAPAC.
3.2Once all the requirements are met and the CAPAC ETG supports a recommendation for accreditation, the CAPAC ETG and the ANSI staff prepare recommendation for accreditation for the full CAPAC. CAPAC then votes on granting accreditation. CAPAC may approve the assessment report with non-conformities as well as corrective action plans for removing the non-conformities. CAPAC will request the ANSI staff to inform the certificate issuer of the specific date for the completion of the corrective actions.
3.3Following the approval by the CAPAC, ANSI staff shall promptly notify the applicant in writing of the accreditation action. No verbal notification will occur.
3.4In cases where applicants have failed to address non-conformities within the agreed-upon timeframes that are determined by the assessors and CAPAC, the CAPAC ETG may recommend denial of accreditation to the CAPAC. If the CAPAC agrees with the ETG that there is substantial evidence to support denial of accreditation, the committee may vote to deny accreditation. ANSI staff shall promptly notify the applicant in writing and include the basis for the Committee's decision along with information on any additional steps to be taken by the applicant. Even when the decision is denial of accreditation, all fees associated with this review process must be paid. The applicant may appeal this CAPAC decision in accordance with ANSI’s appeals procedures.
3.4.1The applicant may choose to re-apply for ANSI for accreditation at any time after accreditation has been denied. The applicant must begin the ANSI process from the beginning, including the preliminary application to enter the accreditation process and all relevant fees.
4Maintenance of Accreditation During Surveillance and Reassessment
4.1Results of surveillance or reassessment, including reports, non-conformities along with corrective actions, opportunities for improvement (OFI)s and commendations, as well as recommendations of the Evaluation Task Group (ETG) are reviewed by CAPAC.
4.2CAPAC shall either vote to grant continued accreditation, in those cases when there have been no nonconformities identified or all have been closed, or to request further corrective actions, providing the certificate issuer with the due date. Depending on the severity of non-conformities and the length of time taken by the certificate issuer to provide corrective actions, CAPAC may vote to suspend or withdraw accreditation or place the certificate issuer on probation.
4.3If the accreditation certificate expires prior to a CAPAC decision on the renewal of accreditation and the reassessment process is in progress, the program director shall extend the validity by 90 days. ANSI staff shall issue a new certificate of accreditation reflecting the 90 day extension. Any further extension will require a vote by CAPAC. Upon reaccreditation, the CB shall be issued a new certificate of accreditation based upon the original effective date of granting accreditation, regardless of any extension(s).
5Extension and Reduction of Scope of Accreditation
5.1Extension of scope
5.1.1Decisions on scope extension are reviewed by CAPAC in a manner similar to the review of initial accreditation decisions. In many cases scope extension is sought by the accredited certificate issuer during their regular surveillance and reassessment cycle. In such case, the regular annual assessment shall include an assessment of the scopes (certificate additional programs) submitted for scope extension. However, ANSI shall also review stand-alone scope extension requests and may conduct (as a minimum) a document review and, if necessary, an onsite assessment.
5.1.2Scope extension fee as documented in the fee schedule procedure is payable upon submission of the request by the accredited certificate issuer.
5.1.3If non-conformities which are identified specifically during the scope extension assessment have been found by ANSI assessors and CAPAC and affect the compliance of the other accredited programs, they shall be treated as regular non-conformities against the accredited certificate issuer and may result in CAPAC’s appropriate accreditation decision concerning the originally accredited programs.
5.2Reduction of scope
5.2.1CAPAC may decide to vote to reduce the scope of accreditation of a certificate issuer if some of the accredited programs have been found to be in non-compliance with requirements while others, as well as the system and the organization as a whole are compliant.
5.2.2Accredited certificate issuer may choose to voluntarily request reduction in the scope of its accreditation at any time by submitting a written notice to ANSI.
6Probationary Accreditation, Suspension and Withdrawal of Accreditation
6.1If an accredited certificate issuer has failed to correct one or more non-conformity(ies) within a designated period of timeframe, the CAPAC may place it on probationary accreditation. Once placed on probationary accreditation, the certificate issuer shall be given a reasonable period of time to correct the non-conformity(ies) with a warning that failure to do so may result in CAPAC vote to suspend or withdraw accreditation.
6.2The CAPAC shall vote to withdraw ANSI accreditation from a certificate issuer if any of the following occurs:
a)filing of any involuntary petition of bankruptcy;
b)liquidation of the business or the organization;
c)discontinuance of the accredited certificate program;
d)certificate issuer’s failure to correct a nonconformity in its program that has been requested by ANSI;
e)misuse of the ANSI accreditation symbol;
f)it is revealed that the information contained in the original application or subsequent reports is fraudulent;
g)failure to comply with ANSI policies and procedures, including the failure to pay the accreditation fees.
6.3If at any time during the term of the contract the certificate issuer defaults in any way on its obligations to ANSI, ANSI shall call this administrative infraction to the attention of the organization for immediate correction. The communication shall include a notice that if the administrative matter is not immediately corrected, it will be brought to the attention of the CAPAC, which may vote to place the organization on probationary accreditation. If the matter remains unresolved, the CAPAC shall be notified and may vote to withdraw accreditation of the certificate issuer.
6.4An accredited certificate issuer has the right to voluntarily withdraw its ANSI accreditation at any time for any reason. Request for withdrawal must be submitted in writing by an authorized representative of the organization.
6.5Based on the recommendation of ETG, CAPAC may vote to suspend accreditation of one or more accredited certificate programs belonging of the accredited certificate issuer. Reasons of suspension may include lack of resolution of non-conformities or violation of ANSI policies or procedures, including the terms of the Program Agreement. Suspension decision must be accompanied by a defined timeframe during which the certificate issuer must address the underlying problems or face the further CAPAC decision on withdrawal of accreditation.
6.6When ANSI accreditation is withdrawn (voluntarily or involuntarily) or suspended, ANSI staff shall publish a notice in Standards Action and otherwise publicize the action in any way that ANSI deems appropriate. Upon withdrawal or suspension of its accreditation, a certificate issuer must discontinue use of the ANSI accreditation symbol, all advertising material which references the Certificate Accreditation Program and return any accreditation documents deemed appropriate including its accreditation certificate to ANSI.