by Tom Sefcik, ACSW, MBA
Personnel Resources Required for CARF Accreditation
CARF accreditation requires both preparation and readiness for the surveyor. “How do I get ready?” is the primary question that those who are applying will ask, and several answers exist. A responsibility that is critical for a successful survey and accreditation is being prepared with the appropriate personnel to be the liaison for CARF.
The standards are organized under two primary headings – Administrative and Program, with possibly one type of CARF surveyor for each. Leadership, Governance, Strategic Planning, Legal Requirements and Legal Rights, Financial Planning Risk Management, Health and Safety and Human Resources are categorized under Administration, while Assessments, Treatment Plans and Discharge are regarded as Program.
CARF Administrative Surveyor Expectations
For each Administrative section, the CARF surveyor will ask to speak with someone from that respective area. Below are the personnel that should be consulted and the topics the surveyor will cover. The individual who is addressing these specific sections should be made fully aware of what will be covered and be available when a meeting time is established. The surveyor may be able to be more flexible, and a 20-30 minute phone conversation may be all that is required, although a CARF consultant from PowderHorn Consulting will recommend an in-person interview.
Leadership – This section will require input from the executive director, in which he or she will cover corporate compliance, cultural competency, diversity and possibly ethics.
Governance – (If applicable) The board can address governance, although organizations typically don’t get involved with it. A provider cannot get recommendations, nor can it be on their certificate if they do not provide access to governance.
Strategic Planning – If the organization employs a Quality Assurance staff, they will be responsible for addressing this; otherwise, the executive director can discuss it. A CARF consultant from PowderHorn Consulting will recommend that the four surveys be conducted at least six months and then 4-6 weeks in advance of the survey and then complete an analysis. This will show how the organization is improving.
Legal Requirements, Legal Rights, and Risk Management – Quality Assurance, Quality Improvement staff or the Executive Director can report for this section, depending on the organization’s size.
Financial Planning – The Finance Officer of the organization or the Executive Director can provide the annual review and the annual CPA audit.
Health and Safety – Different departments can be called upon to supply information for CARF accreditation for this section including the Executive Director, the Clinical Director or the Medical Director.
Human Resources – Several items are required for this part of the survey and the Personnel Director would be responsible.
Technology – An IT director can address the Technology section and if one is not on staff the responsibility will fall to the Executive Director.
CARF Program Surveyor Expectations
The clinical staff of the provider being surveyed will address Assessments, Treatment Plans and Discharge. The staff should be knowledgeable about what is expected in the standards, and when they are following in detail what is in the treatment plan, making progress notes and conducting discharges, they should be able to discuss it during the survey. A CARF consultant will suggest a mock CARF survey to prepare the organization for the actual event, and this will help make the actual process run much more smoothly.
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.