What Happens After Survey Day: A 90-Day Action Plan
Nonprofit board members discussing strategic planning goals
Survey day marks an important milestone, but it does not conclude the accreditation process. The 90 days that follow shape how findings are resolved, how staff experience accreditation, and how prepared the organization will be for the next review. A clear, time-based approach helps organizations stay focused and avoid missteps during this critical period.
Below is a practical way to navigate the first 90 days after survey day.
Days 1–30: Understanding the Survey Findings
In the weeks following the survey, the accrediting body issues a formal report identifying any standards where full compliance or conformance was not demonstrated. Most organizations receive at least some findings, even when preparation has been thorough. The number of findings varies, but what matters most is how clearly each one is understood.
During this first phase, leadership and key staff should review the report carefully and consistently. Each finding should be examined to understand:
The intent of the standard
The specific issue identified by the surveyor
The evidence that was missing, incomplete, or inconsistent
This period should be dedicated to clarity. Acting too quickly or making assumptions about what a finding means often leads to correction plans that do not fully address the issue.
Days 31–60: Corrective Action and Submission
Once findings are clearly understood, attention shifts to developing and submitting corrective action plans. Accrediting bodies expect these plans to directly resolve each cited issue. Plans that are vague, overly broad, or loosely connected to the findings are often rejected.
Strong corrective action plans during this phase:
Address each finding individually
Identify specific, measurable actions
Assign responsibility and timelines
Describe how compliance will be monitored and sustained
Accrediting bodies review plans closely to determine whether the organization understands the standard and can maintain compliance over time. A large number of unfocused actions can suggest confusion rather than commitment.
Implementation timelines differ by accreditor. For example, The Joint Commission requires organizations to complete corrective actions before submitting Evidence of Standards Compliance, while other accrediting bodies may allow actions to be implemented after plan approval. Understanding these requirements early helps avoid delays.
Days 61–90: Approval, Communication, and Stabilization
Once the accrediting body approves the corrective action plan, the focus shifts to follow-through and visibility. Approval confirms that the plan adequately addresses the findings, but it also signals the start of continued oversight.
The standards cited during the survey remain an area of focus for the next review cycle. Organizations should be prepared to demonstrate sustained compliance, supported by active monitoring and documentation. Some accrediting bodies require annual or periodic reporting, while CARF requires ongoing quality and conformance reporting as part of continued accreditation.
This phase is also the right time to communicate accreditation outcomes. Internally, organizations should share the results and recognize the contributions of staff, leadership, board members, and contracted personnel. Externally, key stakeholders may include funders, referral sources, insurers, regulators, and community partners.
Accreditation should be visible and clearly explained. Many organizations update their websites, marketing materials, email signatures, recruitment materials, and social media to reflect accreditation status and explain what it represents in terms of quality and safety.
Beyond 90 Days: Sustaining Compliance
Accreditation is an ongoing commitment. After the first 90 days, organizations should continue to focus on maintaining compliance through regular review of policies and procedures, staff training, orientation of new hires, internal audits, mock surveys, and required reporting. Staying current with updates to accreditation standards reduces risk and supports long-term readiness.
Moving Forward
The period after an accreditation survey sets the foundation for long-term compliance. Organizations that approach this period with structure, clarity, and follow-through strengthen compliance and reduce future survey risk. With the right focus, accreditation becomes part of how the organization operates rather than a task reserved for survey cycles.
Accreditation Guru offers maintenance services to help organizations sustain accreditation through ongoing review, monitoring, and expert guidance, reducing risk and strengthening readiness for future surveys.
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Note: The steps outlined above are intended as general guidance. Specific post-survey requirements, timelines, and deadlines vary by accrediting body. Always refer to your accreditor’s official communications and guidance to confirm what applies to your organization.