4 Areas that May Disqualify you from CARF Accreditation

4 Areas that May Disqualify you from CARF Accreditation

By Tom Sefcik, ACSW, MBA

CARF accreditation is a goal of many rehabilitation facilities, and according to some CARF consultants, it is difficult to not become accredited. This does not mean that an organization can apply for a CARF survey and expect to do no planning and then receive a three year accreditation, but a well-run facility that has worked with a CARF consultant and that is organized and has prepared a presentation can expect to receive
accreditation. There are specific areas that are hot spots for review, so it’s a good idea to make sure that these tasks are well accounted for to receive the maximum three year accreditation status.

Health and Safety Standards

The areas to be prepared for on the health and safety standards on CARF accreditation are keeping records organized and up-to-date. The simpler the process is, the easier it will be to follow as well. When an organization is formed, it should consider that some form of accreditation will be sought after in the future, so setting up procedures that are easy to follow is important. If your organization has been in existence for some time, and your record-keeping and processes are not streamlined, consider revising them to more simple terms.


The health and safety standards are established to improve your practices as well. If you have no critical incident reports it may mean that the process is too complicated or that employees are not trained to handle one. Be sure that your organization is not missing out on opportunities for improvement with complicated procedures that are not regularly pursued. Conduct emergency drills as needed, and take care that they are
appropriate for the type of likeliness of its occurrence, and then documented that the drill took place.

Assessment Treatment Plan and Medication Management

A facility does not have to meet all of the standards, but these two areas should both be strong to receive CARF accreditation. While medication management is not always recommended to have in place or to undergo the review, this area in particular should not be weak and should conform strongly to the standards. Assessment treatment plans also should be thoroughly examined and implemented between the time the application is made and the surveyor arrives.

Quality Records review

A documented quarterly records review is expected from an organization for CARF accreditation. The report should address the quality of service delivery, the appropriateness of services and the patterns of service utilization. This is a critical area that a CARF surveyor will look at and expect conformity to the standards.

To receive CARF accreditation an organization must first be organized and then have everything ready for the surveyor. Six months of data is required to show that the provider has been implementing the CARF standards. Presentation is critical to a successful accreditation, and when the information is readily available, even presented to the surveyor when they arrive at the hotel; it will cut down on the frustration of the
surveyor and the team to be surveyed. CARF accreditation will take work to happen, yet when it is complete you will have a much more precise and well-run facility.


PowderHorn Consulting is staffed by professionals who have served as providers, executives on treatment organizations and have an extensive history as CARF surveyors and can assist and answer any questions you may have in the CARF accreditation process.