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The Certification Process

Let ACSC make the audit process simple and pleasant. We do not hunt for nonconformities, we seek evidence of conformance.

Keeping our sights on the goal of effective and value added auditing, sets us apart from our competition, in addition to having some of most competitive costs in the industry.

Transfer Existing Certifications

Any organization that is currently certified to a standard and industry code that ACSC is accredited for by an IAF/MLA recognized accreditation body (e.g., IAS, ANAB, etc.) may transfer their exiting certification to ACSC. This transfer can occur at any point during the registration cycle, and does not have to wait until a Recertification event. After the organization’s application has been reviewed and approved, ACSC will conduct a certification documentation transfer review.

This review requires ACSC to validate that the existing certification has been issued by an accredited certification body. This means that the accreditation body certifying the registrar must be a signatory of the International Accreditation Forum (IAF). If the certification body is not properly accredited, then ACSC cannot transfer their certificate, and in order to become certified by ACSC, a full Stage 1 and Stage 2 audit must be completed by the organization.

After a successful transfer review, ACSC will issue the client a new ACSC certificate and continue the current audit cycle. Please note that certificate transfers can occur at any time, not just during a recertification audit event.

How does a virtual audit work?

ACSC will establish a link between itself and the client using virtual media such as Microsoft Teams, GoToMeeting, etc. There will be an Opening meeting for all invitees to introduce the audit team and review the audit plan. The ACSC auditor(s) will then begin to conduct interviews and review relevant documentation using document share technology.

For conducting operational staff interviews, ACSC relies on the Apple iPhone Facetime app or WhatsApp (for Android users) as the virtual media source. This permits the ACSC auditor to conduct interviews with personnel with support from the client representative. As with any audit, ACSC is seeking evidence of conformance to the requirements of the Standard and the organization’s management system. If there are findings discovered during the audit, they will be shared with the client immediately for discussion.

At the conclusion, there will be a virtual Closing meeting to present the results of the audit. The corrective and preventive action process is unchanged for virtual audits; a final report will be issued to the client within 5 business days of the Closing meeting.

New Certifications

All new certification clients to ACSC must first complete an Application for Certification Services form, regardless if it’s a new certification or the transfer of an existing certification. ACSC management then reviews the application and may contact the applicant to fill in any missing information. Once the application is accepted, ACSC uses the information to determine if we have any conflict of interest and the industry code accreditation to perform the audit. If the application is accepted ACSC then follows our established process to determine audit duration requirements for the applicant. From here, a formal quotation is developed and provided to the potential client.

Application

After the quotation is approved, ACSC and the new client discuss audit dates and the selection of auditor(s) for the upcoming audit events. Once selected, the designated Lead Auditor will make formal contact with the client to finalize plans for the initial readiness visit (Stage 1) and tentative dates for the Registration Audit (Stage 2).

Download Application (PDF)

Audits Types

Below are short descriptions of the typical audits that are performed as part of the third party certification process.

Stage 1

The purpose of the Stage 1 audit is for the Lead Auditor to familiarize himself/herself with the operations and to perform a high level assessment of the existing management system documentation, in order to determine if the management system is appropriate and mature enough for a Stage 2 audit to commence. There are no written non-conformities issued during a Stage 1, only written comments about the conditions of the management system and its level of readiness for a Stage 2 audit. Comments will include areas of nonconformance (if observed), but a formal non-conformance will not be written by ACSC.

Stage 2

At the Stage 2 audit, the audit team reviews documentation such as procedures, work instructions, process maps, forms, records, etc., and interviews randomly selected personnel to collect objective evidence of conformance to the applicable standard. If the ACSC audit team identifies a nonconformance, they will promptly explain their view to the client and (if in agreement) issue a Correction & Corrective Action (CCA) request to the organization. If there is any disagreement between the client and the ACSC audit team, the audit team will still issue the CCA, however, the client will have an opportunity to appeal the finding to ACSC management, following completion of the audit. At the conclusion of the audit activities, the ACSC audit team will present a summary of the results of the audit to the client along with their formal recommendation for (or against) registration to the standard(s). The audit report will then be delivered to ACSC for formal review and a Certification Decision will be made and communicated to the Lead Auditor and client contact. The certification is valid for 3 years, pending successful completion of yearly surveillance audit(s).

Surveillance

Following certification, there must be semi-annual or annual (typically annual) surveillance audit visits to maintain certification. The initial surveillance audit after the initial Stage 2 certification audit, must be completed prior to the 1-year anniversary date of the Closing Meeting of the Stage 2 Audit, or the certification will be temporarily suspended. Subsequent surveillance audits must be conducted around the same timeframe each year (typically +/- 40 days). The process of the surveillance audit is very similar to a Stage 2 audit, just the audit duration is less. We encourage ACSC clients to consider a surveillance audit a wellness visit!

Recertification (or Reassessment)

Every 3rd year, a Recertification Audit shall be conducted. This audit is very similar to the initial Stage 2 audit. The Recertification Audit must be completed in a timeframe (early enough) that permits ample time for the client to address any identified nonconformities prior to expiration of the current certificate. Therefore, Recertification Audits are generally conducted 45-60 days prior to current certificate expiration. Upon successful completion of a Recertification Audit, ACSC will issue a new certificate, valid for another 3 year period, pending successful completion of yearly surveillance audit(s).

Continued Certification

To maintain certification with ACSC, an organization must stay up to date on 4 tasks:

  • Conduct required annual Surveillance Audits
  • Complete Recertification Audits every three years
  • Close all issued Correction and Corrective Actions (CCA’s) requiring a corrective action response by the organization within the appropriate timeframe, as defined by ACSC and communicated to the organization
  • Pay all invoices in full within acceptable timeframes

Appeals and Complaints

ACSC will take into account the following information when reviewing an appeal, dispute or complaint:

  • The Requirement(s) of the applicable Standard
  • ACSC accreditation/scheme requirements
  • Results from similar appeals, disputes or complaints
  • Information received from other parties to the appeal, dispute or complaint

Relevant parties or individuals may be interviewed, but will be excluded from the decision making process, including those who are perceived to have a vested interest in the outcome of the appeal, dispute or complaint. Persons (maximum of 3) reviewing the appeal shall be appointed by ACSC and shall be independent of the issue being reviewed. Members of the appeals panel will be made up of individuals employed by ACSC or Advisory Board members, not previously involved in the subject of the appeal or complaint. The appellant shall be informed of the members of the appeal panel and have an opportunity to object to any of the selections. ACSC shall make every effort to have appeals heard within 60 days.

Appeals are not legal proceedings and therefore, the appealing organization shall notify ACSC at least 14 days in advance if an appellant intends to have legal counsel present for the appeal. The decision made may reflect one or more of the following results:

  • A decision to uphold the nonconformance, recommendation or decision
  • A decision to withdraw or reclassify a nonconformance, recommendation or decision
  • A requirement for the client organization to undergo a special audit as part of the investigation
  • A nonconformance being issued to the client organization
  • Enforcement action

File An Appeal Or Complaint


Suspending, Withdrawing or Reducing the Scope of Certification

ACSC may place a client organization on Suspension for failure to conform to any of the requirements for certification. This may include, but is not limited to, the following:

  • Failure to conduct 3rd party audits within the required intervals;
  • Failure to submit acceptable CAR responses within the required timeframe;
  • Repeat of a Major CAR; or
  • Failure to pay an ACSC invoice.

ACSC will notify a client organization in writing of a Suspension decision and all related details. While under suspension the client organization’s Certificate of Registration will be treated as invalid and the client organization must refrain from further promotion of its registration status until the suspension is lifted or expires. If the client organization is placed on suspension and is part of a corporate registration scheme, any affected sites may be placed on suspension until the issue(s) that resulted in the suspension is cleared by ACSC.

ACSC may conduct an on-site audit of appropriate length to verify effective implementation of all corrective actions, before lifting the suspension. If the issue(s) are not resolved prior to the suspension expiration date, ACSC may withdraw registration of the client organization’s Certificate of Registration. The client organization will then have thirty (30) days to appeal the withdrawal decision.

Voluntary Suspension of Certification

The client organization may elect to voluntarily withdraw their Certificate of Registration if the client organization is unable to schedule the Recertification Audit prior to the current certificate expiry date. Certain circumstances may permit an audit to be scheduled within 6 months of the date of voluntary withdrawal of the certificate provided the client organization can demonstrate it has maintained conformance to the management system(s) it was certified to prior to voluntary withdrawal. Each circumstance will be reviewed by ACSC and audit duration needed to re-instate the certificate will be determined on a case by case basis.

Withdrawing Certification

ACSC may withdraw their Certification of Registration from any client organization at any time, for failure to conform to any of the certification requirements. Certification withdrawal is generally preceded by a suspension. ACSC will notify the client organization in writing, of certification withdrawal. Upon notice by ACSC to the client organization of withdrawal, the client organization shall immediately stop the use of the ACSC and accreditation body marks.

Expanding or Reducing the Scope of Certification

ACSC may expand the scope of certification when the certified organization request an expansion, or when it is determined by ACSC that the current scope is not accurate. Expansion of scope may occur during a regularly planned audit event or a Scope Expansion Audit may be needed, depending on the situation and needs of the certified organization.

ACSC shall reduce the scope of certification to exclude the parts not meeting the requirements, when the certified organization has persistently or seriously failed to meet the certification requirements for those parts of the scope of certification. Any such reduction will be in line with the requirements of the standard used for certification.

Restoring Certification

Following withdrawal or suspension of the Certificate of Registration, the client organization may be reinstated once ACSC has reevaluated the site(s) affected and has verified that any items of nonconformance have been satisfactorily resolved. At this point, ACSC will notify the client organization in writing that it is authorized to use the ACSC and accreditation body marks in connection with the site(s). Fees associated with these activities will be billed according to current ACSC billing and expense rates.