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CHSPS — Commission for Health, Safety & Professional Standards
CHSPS-ACC-109 · Published Procedure · Edition 2026.1

Maintaining Accreditation

Accreditation is a continuing relationship, not a plaque. These are the obligations that keep accredited status meaningful between reviews.

Ongoing cycleContinuous accountability

What happens after a decision

1
Annual reportingSubmit required status updates, activity volumes and other scheduled information.
2
Material change noticeTell CHSPS when structure, ownership, scope or key operating conditions change.
3
Interim follow-upRespond to required monitoring, corrective action plans or focused reviews.
4
Incident & complaint oversightSerious events, integrity concerns and substantiated complaints can trigger action.
5
Renewal reviewA new full-cycle review confirms that accreditation remains deserved.
Public trust depends onCurrent information, not only the original decision file
Typical artifactsAnnual report, change log, updated policies, performance summaries

Maintaining accreditation means keeping the file current and showing that the accredited system continues to operate as represented.

Annual reporting

Each accreditation record submits a short annual report by its accreditation anniversary — organizations holding multiple CHSPS accreditations file one consolidated report with a per-scope attestation inside it (see Multiple Programs & Portfolios) — covering: candidate/learner volumes, pass or completion statistics where applicable, complaints and appeals summary, changes to key personnel or governance, and confirmation of continued conformity. Late reports trigger a 30-day cure period; unresolved non-reporting is grounds for suspension.

Material change notification

Notify CHSPS before implementing changes that could affect conformity, including: changes of ownership or organizational control, changes to certification scheme scope or eligibility, replacement of the assessment model or delivery mode, changes to renewal requirements, changes to an ABC, WBL or specialty accreditation scope or control model, changes to an add-on, supplement, scope module or Certified System, and outsourcing of core functions. CHSPS determines whether the change requires acknowledgment, focused review, or full re-review. Minor changes (editorial updates, staffing below leadership level, routine item maintenance) are reported in the annual report.

Scope changes

Scope expansion requires review before the expanded scope is listed. A limited change within an already accredited program uses the focused scope-change review (from $900); adding a separate certification program under the same organization uses the $2,500 additional-program review fee. Course additions follow the published course-pricing rules. Scope reductions are recorded in the public verification with effective dates. See the controlled Fee Schedule for the current amount that applies.

Continuing obligations

  • Use the mark only per the Mark & Claims Policy, within scope, while status is active
  • Cooperate with complaint investigations and any for-cause review
  • Maintain records supporting decisions for the published retention period
  • Pay annual fees; nonpayment beyond 60 days triggers suspension procedures

Suspension & reinstatement

Suspension is a defined, time-limited state: the public verification shows it, mark use pauses, and a corrective-action plan with deadlines governs the path back. For an administrative maintenance lapse, CHSPS provides a 30-day cure period after the due date; unresolved annual reporting or fee obligations after 60 days may trigger suspension. Reinstatement follows verified correction, payment of amounts properly due, and the applicable administrative reinstatement fee. Failure to cure within 60 days after suspension may lead to withdrawal for cause. Suspension is different from expiration: suspension occurs during an existing term; expiration means the term has ended.

Voluntary withdrawal

An organization may surrender accreditation at any time in writing. The verification records the withdrawal as voluntary with its effective date; mark use ceases on that date.

Forms: Consolidated Annual Report template (DOCX) · Material Change Notification (DOCX) — submit through the applicant contact channel identified in the accreditation record or engagement schedule.

Renewal / re-accreditation

Renewal workspaces open 9 months before expiration. CHSPS recommends submission about 6 months before expiration and defines a renewal as timely when the complete reaccreditation application and required renewal fee are received at least 90 calendar days before expiration. If a timely, complete renewal remains under CHSPS review at expiration, status changes to Accredited — Renewal Review Pending; the existing accreditation remains active until the renewal decision, provided the organization remains responsive and no separate suspension or withdrawal basis exists. This continuation protects organizations from CHSPS processing time and carries no extension fee.

Late renewal, expiration & reinstatementWhat happens if renewal is late or accreditation expires?

CHSPS separates a late filing from an expired accreditation. A fee can cover extra administrative or expedited work, but no fee buys extra accreditation time, restores status automatically, or changes the technical decision.

90+ days before expiration

Timely renewal

Normal renewal fee. If CHSPS has not completed review by expiration, the public verification may show Accredited — Renewal Review Pending and mark rights continue through the decision.

89–0 days before expiration

Late renewal

CHSPS may accept a complete late renewal with an expedited-processing fee equal to 15% of the applicable renewal review fee (minimum $150). A decision before expiration is not guaranteed. Any temporary continuation requires written CHSPS approval and is not purchased by the fee.

1–90 days after expiration

Expired — reinstatement route

Status remains Expired while reviewed. Mark rights stop and the public record shows the lapse. CHSPS may accept a reinstatement review using current renewal evidence for the normal renewal review fee plus a $500 reinstatement-processing fee. Any new term begins on the new decision date; CHSPS does not backdate accreditation across the lapse.

More than 90 days after expiration

Initial application required

The organization returns through the initial accreditation pathway and current initial fees. Prior evidence may be reused when still current, but prior status creates no presumption of approval.

Extraordinary circumstances. Before expiration, an organization may request a documented extension for events outside its reasonable control (for example, a declared disaster or severe operational disruption). CHSPS may approve a limited extension of up to 90 days and may waive a late-processing fee when doing so is consistent, impartial and documented. Ordinary lack of preparation is not an extraordinary circumstance.

At expiration. Unless a timely renewal is pending or CHSPS has issued a written temporary continuation, active accreditation ends at the close of the published expiration date. The public verification retains the historical record, verification shows Expired, and use of the CHSPS accreditation mark or present-tense accredited claims must stop. See the full expiration & reinstatement guide.

Corrective-action limits & decision cadence

Corrective-action responses are due within the window stated in the findings letter (normally 90 days, maximum two cycles); unresolved findings after the final cycle proceed to decision in the documented record. Emergency changes implemented to protect candidates or the public may precede notification, which must follow within 5 business days. The Decision Committee meets on a published monthly cycle, and decisions target issuance within 15 business days after completed technical review.

Program-specific planning

What maintenance looks like for each accreditation

The maintenance procedure is common across CHSPS, but the scope-specific questions differ because the underlying standards differ. Use this overview to plan the records your team will keep current.

Maintenance terms, annual reporting emphasis and renewal review by accreditation pathway
AccreditationTermAnnual reporting emphasisRenewal review
CERTCertification Program Accreditation5 yearscandidate and examination activity volumes, pass/completion or score-reporting information where applicable, complaints, appeals, irregularities and material security incidents$4,500Target submission 6 months before expiration
EDPEducation Provider Accreditation3 yearslearner and educational-activity volumes, changes to curriculum systems, delivery technology or assessment, learner complaints, accessibility issues and material incidents$2,600Target submission 6 months before expiration
COURSECourse Accreditation3 yearscourse availability, enrollment and completion activity, material content/version changes and evidence currency, faculty/author or assessment changes$800 per courseTarget submission 6 months before expiration
HSAIHigh-Stakes Assessment Integrity Accreditation3 yearsassessment administrations and integrity-control activity, identity exceptions, security incidents and irregularities, accessibility / due-process issues$3,500Target submission 6 months before expiration
REARemote Examination Administration Accreditation3 yearsremote examination administration volume, candidate system-check and readiness performance, identity exceptions and material technology interruptions$3,500Target submission 6 months before expiration
MSSMedication Safety Systems Accreditation3 yearsmedication-safety activity and significant event trends, high-alert medication and risk-control changes, prescribing/CDS, verification, preparation, storage or administration changes$3,500Target submission 6 months before expiration
WCAHealthcare Workforce Competency Assurance Accreditation3 yearsworkforce population and role-framework changes, credential-verification exceptions and readiness activity, initial / continuing competency completion and lapsed requirements$3,500Target submission 6 months before expiration
CEQClinical Education Quality Accreditation3 yearslearner and clinical-education activity volumes, needs/objective/content and faculty changes, simulation, skills, assessment and completion activity$3,500Target submission 6 months before expiration
AIGAI Governance & Assurance Accreditation3 yearscurrent inventory of consequential AI systems in scope, new, retired or materially changed AI systems / intended uses, validation / revalidation and ongoing monitoring results$3,500Target submission 6 months before expiration
ABCAssessment-Based Certificate & Micro-Credential Accreditation3 yearscredential volume, assessment and completion rules, recipient records, verification controls, material platform changes and digital-integrity incidents$1,500Use the renewal target stated in the engagement schedule
WBLWork-Based Learning & Competency Program Accreditation3 yearslearner and site activity, supervisor/preceptor changes, observed-performance assessment and completion decisions, safety/escalation events, accessibility/fairness issues, partner controls and material program changes$3,000Target submission 6 months before expiration
Defined offering maintenance.HSAI-AI, ALT-320 and WCA-TEL maintenance attaches only to the approved parent accreditation and scope. APS and ALT-720 use Certified System surveillance and recertification. Exact fees and status classes are listed in the Fee Schedule and applicable official record.
One applicant legal entity, one consolidated annual report.If the same legal entity holds multiple CHSPS accreditations, organization-wide information is confirmed once and each accredited scope receives its own short attestation. Related legal entities may share one My CHSPS portfolio workspace, but each legal entity retains its own attestation/report record and accreditation obligations.
CHSPS reference criteria

Quantitative operating targets for this function

These CHSPS reference criteria define the current operating and interpretation ranges for this function. They support consistent review and quality monitoring without replacing clause-level professional judgment.

CHSPS Reference Criteria 2026.1. These are CHSPS-adopted operating/reference criteria for consistent interpretation and quality monitoring. They are not empirical benchmarks, industry norms or automatic accreditation cutoffs unless a normative clause expressly incorporates a value. CHSPS will recalibrate them when sufficient validated operational data are available.
Methodology
MAINT-R01

Annual report submitted by due date

Preferred100%
Watch95.0–99.9%
Review< 95.0%
MAINT-R02

Material changes reported within required window

Preferred100%
Watch95.0–99.9%
Review< 95.0%
MAINT-R03

Corrective actions closed by due date

Preferred≥ 95%
Watch90.0–94.9%
Review< 90.0%
MAINT-R04

Critical incident notifications on time

Preferred100%
Watch95.0–99.9%
Review< 95.0%
MAINT-R05

Repeat major finding rate

Preferred≤ 5%
Watch5.1–10.0%
Review> 10.0%

Where this controlled procedure and an informational page-level summary differ, this controlled procedure governs.

Merger, name change, deadline problem, evidence limitation or another unusual situation?

Use the special-situations guidance instead of guessing which maintenance record applies.

Changes & special situations