TL;DR: It is possible for an organization to receive no recommendations after a CARF accreditation survey. To optimize the survey, it’s a good idea to be aware of mistakes to be prepared for, including:
- Making one person responsible for the entire process.
- Underestimating the time needed for accreditation
- Unpreparedness of the organization
- Failure to align CARF policies with staff practices
- Inconsistent documentation practices
- Overlooking the ongoing nature of accreditation
CARF surveyors are looking for more than an organization following policies when they conduct an accreditation survey. CARF International holds an expectation that a facility can provide evidence that practices are followed through client interviews, record-keeping, outcomes, and that compliance activities are completed.
To meet these expectations, organizations seeking CARF accreditation (behavioral health, child and youth services, employee and community services providers, medical rehab and home health) will benefit by immersing themselves and embracing the process for better service for their clients. A few steps, listed below, will help a provider eliminate mistakes and receive a three-year CARF accreditation with as few recommendations as possible.
Mistake: Assigning the accreditation process to one individual.
How to avoid it: Share the load and share the benefits of CARF accreditation! The process of accreditation requires participation from multiple functions within the organization. The leadership and clinical team, compliance, operations, program managers, safety, human resources, and other participants all contribute. Setting up a team at the beginning of the process, scheduling regular meetings, and setting expectations for accomplishing goals will spread the load and reach success with participation from the team.
Mistake: Rushing the process for accreditation
How to avoid it: When an organization decides to pursue CARF accreditation, a first preferred step is to inform the employees and contractors that it will be taking place. Providers must provide six months of tracking data, and setting up systems to accomplish this takes some time. Average predicted time to receive accreditation takes a minimum of six months up to 18 months.
Once the detailed, over 30-page application has been filled out, assemble a plan identifying how the organization complies. For first-time CARF accreditation applicants, hiring a CARF consultant can help simplify the procedure with tried-and-true methods.
After reviewing the expectations and roles, assign an individual to lead the process and appoint personnel to manage their roles regarding documentation, facility maintenance, clinical records, and client process evaluation.
Mistake: Gaps in compliance, policy and procedural deficiencies and staff unreadiness at the time of the survey
How to avoid it: A valuable tool to reduce citations, identify gaps in compliance, and prepare staff is to schedule a CARF Mock Survey. This device is a simulated inspection which evaluates an organization’s readiness and checks to avoid citations, find disparities in compliance and documentation, and assesses staff to assure they are ready for the survey.
A Mock Survey involves a CARF accreditation consultant acting as a CARF surveyor who mimics the auditing and evaluation process. The consultant is often a CARF surveyor who is very familiar with what CARF expects to review and can make staff feel more comfortable on the second time around during the actual survey.
Paperwork must show compliance, so strategic plans, policies and procedures, and performance data undergoes a document review, and active and closed clinical records are audited. In addition, a CARF consultant will interview staff and leadership during the mock survey to build confidence for the actual survey. Lastly, the CARF consultant will walk through the physical environment and can point out any discrepancies of compliance.
Mistake: Discrepancy of CARF policy to employee practice
How to avoid it: Also called policy-practice mismatch, it describes how a well-written procedure becomes a problem when it portrays an ideal process rather than the way employees complete the work each day. During a CARF survey, this mismatch can quickly become visible when surveyors compare policies, staff interviews, client records, incident reports, training files, and daily workflows to each other. If employees describe a process that differs from the written policy, the organization may appear inconsistent, unprepared, or unable to demonstrate that its practices are reliable.
Other frequent weaknesses include outdated policies that no longer match current services, unclear ownership of required tasks, overdue policy reviews, inconsistent procedures across multiple locations, incomplete incident follow-up, insufficient outcome data, and corrective actions that were assigned but never verified. These issues often develop gradually as programs grow, staffing changes occur, or documentation systems are added without a consistent review process.
Mistake: Scattered documentation
How to avoid it: For a provider to prove that requirements are completed, reviewed, followed up on and communicated to the appropriate people, documents must be easily accessible to a surveyor to follow the trail. Evidence of training records, policies, risk assessments, incidents and corrective actions, among other documentation should be easily accessible when requested.
Surveyors are not only looking for the existence of documents; they are also looking for a clear trail showing that the organization uses those documents to guide consistent practice.
Mistake: Treating accreditation as a one-time achievement
How to avoid it: Understand that the goal of CARF accreditation is continuous improvement. CARF defines accreditation as “a consultative peer-review process to determine if a provider’s programs and services meet defined international standards of quality in health and human services.”
A provider can be accredited for three years as the optimum accreditation and one year when an organization meets the accreditation conditions but only demonstrates conformance to many (rather than substantial all/most) of the standards. A re-survey is required after one year.
Also, occasionally CARF will accredit a first-time applicant provisional accreditation for one year, requiring a one-year follow-up survey. Lastly, an organization may fail to gain or maintain enough compliance to be accredited.
Mistake Avoidance Summary
The goal of becoming CARF accredited is not to look compliant for several days during the survey or to gather documentation immediately before the survey. The more robust approach is to build a system in which conformance is part of routine operations, i.e.: current procedures are easy to find by staff, policies are reviewed on a schedule, records are completed consistently, incidents lead to documented follow-up, and leadership regularly reviews outcomes and risk trends.
In summary, compliance should be visible throughout normal operations. When documentation, staff practice, leadership oversight, and quality improvement efforts all tell the same story, the organization is better prepared to demonstrate that its services are organized, accountable, and focused on continuous improvement.
PowderHorn Consulting Approach
PowderHorn Consulting (PHC) understands the processes of CARF surveyors because most of our consultants are CARF surveyors ourselves (although a PHC consultant would never conduct a CARF survey for a consulting client).
Hiring PowderHorn Consulting for a mock survey will relieve the stress that employees may face with their first CARF accreditation survey. PHC’s CARF accreditation consultants bring practical accreditation and survey experience to organizations providing behavioral health, child and youth services, employee and community services providers, medical rehab and home health. Contact us today for a free consultation.
Simply Spoken Q & A
Q. How do I avoid the CARF accreditation mistake of assigning the accreditation process to one individual?
A. Engage a team to take on the process of CARF accreditation to assure all areas of the organization are on board and prepared to comply with the CARF standards.
Q. How do I avoid the CARF accreditation mistake of rushing the process for accreditation?
A. Plan, plan, plan. Once the provider has submitted the application, set in motion the plan for all facets of the organization to comply with the CARF standards.
Q. How do I avoid the CARF accreditation mistake of being out of compliance, policy and procedural deficiencies and staff unreadiness?
A. A Mock Survey is an excellent tool to employ with a CARF consultant to go through the process of a survey in advance to find where there are weaknesses in compliance.
Q. How do I avoid the CARF accreditation mistake of discrepancy of CARF policy to employee practice?
A. Inform staff of the upcoming survey to assure that they are following procedure, and to make recommendations to revise as necessary.
Q. How do I avoid the CARF accreditation mistake of scattered documentation?
A. Keep files required for accreditation stored in an orderly manner so they will be easily accessible to surveyors. Training records, policies, risk assessments, incidents and corrective actions, among other documentation are included in the survey.
Q. How do I avoid the CARF accreditation mistake of assuming accreditation is a one-time event?
A. Reading the CARF accreditation application and becoming familiar with the CARF website will provide insight to the purpose of CARF accreditation — ongoing betterment of services to clients.
