§ 280.1023 - Assessment report.

(a) The Accreditor may adopt reporting procedures that suit its needs but, as a minimum, these procedures shall ensure that:

(1) A meeting takes place between the audit team and the applicant's management prior to leaving the premises, at which the audit team provides a written or oral indication on the conformity of the applicant with the particular accreditation requirements and provides an opportunity for the applicant to ask questions about the findings and their basis;

(2) The audit team provides the Accreditor with a report of its findings as to the applicant's conformity to all of the accreditation requirements;

(3) A report on the outcome of the assessment is promptly brought to the applicant's attention by the Accreditor, identifying any nonconformity to be discharged in order to comply with all of the accreditation requirements;

(4) The Accreditor shall invite the applicant to comment on the report and to describe the specific actions taken, or planned to be taken within a defined time, to remedy any nonconformity with the accreditation requirements identified during the assessment, and shall inform the applicant of the need for full or partial reassessment or whether a written declaration to be confirmed during surveillance will be considered adequate;

(5) The report shall contain as a minimum:

(i) The date(s) of the audit(s);

(ii) The name(s) of the person(s) responsible for the report;

(iii) The names and addresses of all sites audited;

(iv) The assessed scope of accreditation or reference thereto;

(v) Comments on the conformity of the applicant with the accreditation requirements and, where applicable, any useful comparisons with the results of previous assessment of the applicant; and

(vi) An explanation of any differences from the information presented to the applicant at the closing meeting.

(b) If the final report authorized by the Accreditor differs from the report referred to in paragraphs (b) (3) and (5) of this section, it shall be submitted to the applicant with an explanation of any differences from the previous report. The report shall take into consideration:

(1) The qualification, experience and authority of the staff encountered;

(2) The adequacy of the internal organization and procedures adopted by the applicant to give confidence in the quality of its services; and

(3) The actions taken to correct identified nonconformities including, where applicable, those identified at previous assessments.