1.
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Complaint must be filled
out and signed by the person(s) or organization filing the
Complaint.
Statue of limitation of the length of time an accredited provider
is must be held accountable for any complaint is 24 months
from the date of the activity in dispute.
The length of time for a CME provider to be held accountable
for a Satellite Meeting, Enduring Materials (publications,
including but not limited to CD-ROM, Video and Audio Cassettes)
will be 24 months from the from the date of the activity in
dispute.
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2. |
Complaint MUST
be mailed by registered mail (or carrier that provide verification
of receipt). |
3. |
Once the Complaint is received, a member
of Accreditation Quality Auditing Committee (AQAC) will review
it to determine whether it is in violation of NEFRON Accreditation
Standards & Policies. |
4. |
If the Complaint was determined not
to be in violation of NEFRON Accreditation Policies & Standards,
the complainant will receive a detailed explanation to the
action taken. |
5. |
If the Complaint was determined not
to be in violation of NEFRON Accreditation Standards &
Policies, the QAC will issue a Letter of Dispute/Investigation
to the accredited provider detailing the nature of the Complaint
and informing them of the Committee’s action to initiate
an immediate investigation to determine its validity. The
Letter of Dispute will also ask the accredited provider to
provide a detailed explanation with supporting documents. |
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a. |
If the accredited
provider fails to respond to the Letter of Dispute/Investigation
within 30 days, the Accreditation Quality Auditing Committee
(AQAC) may choose to change the provider’s accreditation
status “PROBATIONARY”. |
b. |
If the accredited provider responds,
the QAC will determine if an on-site visit is necessary
to determine the validity of the Complaint |
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6. |
If the QAC determines that the information
provided is satisfactory, one of the following actions may
be taken: |
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a. |
If the matter is clear
and proves that the accredited provider was, in fact,
in violation of the NEFRON Accreditation Standards &
Policies, the QAC will raise a Recommendation of Action
to the Accreditation Review Committee (ARC). |
b. |
If the matter is unclear and incomprehensible,
the matter will be referred to the Investigation Committee
(IC) who will look into the NEFRON Accreditation Standards
& Policies in depth to determine the action to be
taken. This may require the Investigation Committee
to hold a meeting with the accredited provider and require
additional materials from the accredited provider to
predetermine the finite details of the violation. |
c. |
If the members of the Investigation
Committee (IC) cannot capitulate on a proposition, the
Committee will issue a detailed compendium report and
present it to the president-elect who will form a Disciplinary
Committee (IC) and call for a meeting with the Accreditation
Quality Auditing Committee, Investigation Committee
and the Accreditation Review Committee (Along with the
formed Disciplinary Committee) to review the compendium
and take votes from all members |
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7. |
Based upon the decision taken by the
three committees, the Accreditation Review Committee (ARC)
will make its proposition to the Disciplinary Committee (DC)
and the Disciplinary Committee will make its final determination
of the action to be taken. |
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a.
Notice of Compliance: |
i. |
If the accredited
provider was found to be in conformity with the NEFRON
Accreditation Standards & Policies, the Disciplinary
Committee will issue a “Letter of Compliance”
in lieu to this Complaint. |
ii. |
A copy of the “Letter of
Compliance” will be mailed by First Class Registered
Mail to the accredited provider and the complainant.
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b.
Notice of Non-Compliance: |
i. |
If the accredited provider was
found to be NOT in conformity of the Accreditation Standards
& Policies the Disciplinary Committee will issue
a “Letter of Non-Compliance” will be mailed
by First Class Registered Mail to the accredited provider
and the complainant. |
ii. |
The “Letter of Non-Compliance”,
which includes the Committee’s decision, enumerated
area(s) of non-compliance, Letter of Dispute, accredited
provider’s response, Letter of Complaint/Investigation,
and the Investigation Committee’s Compendium Report
will be documented in the accredited provider’s
file and a copy will be sent to the accredited provider. |
iii. |
The accredited provider will be
requested to provide documentation of corrective action
to the Accreditation Review Committee (ARC) (cc: Investigation
Committee, Accreditation Quality Auditing Committee).
Additionally, the Committee may request from the accredited
provider to submit an Auditing Report. Failure to comply
with that may affect the accreditation provider’s
accreditation status. |
iv. |
If the accredited provider fails
to respond to the Request for notice of Corrective Action,
the Accreditation Committee may request an immediate
change of accreditation status to “PROBATIONARY”. |
v. |
Once the Auditing Report is received,
the Accreditation Review Committee will determine its
commensuration: |
a. |
If the Report
is Sufficient, the Accreditation
Review Committee will recommend its acceptance.
This Report will be documented in the accredited
provider’s file will be considered for future
re-accreditations. |
b. |
If the Report was Insufficient,
the Accreditation Review Committee may request
additional information from the provider or recommend
a change in accreditation status to “PROBATIONARY”. |
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vi. |
If the accredited provider fails
to provide the requested Auditing Report, the Accreditation
Review Committee may request a team of surveyors to
conduct an on-site visit or a change in accreditation
status to “PROBATIONARY”. |
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