On-site and remote CARF consulting services:

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Mock Surveys - Onsite reviews and mock surveys are often the best way to prepare the organization for an actual CARF survey.  This can be an efficient way to become familiar with the survey process. Mock surveys are useful when preparing for initial accreditation, when a new program is added under a currently accredited organization, or in preparation for a re-survey.  Mock surveys are individualized for each organization, and can include:

• Pre-survey contact and review of non-confidential document prior to the mock survey

• Orientation Conference and tour

• On-site review of policies and procedures, clinical forms, administrative and program documents, and client records, as well as interviews with governance, leadership, funders, staff, and clients

• Exit Conference with review of draft mock survey report

• Debriefing of leadership and selected personnel

• Finalized report with recommendations and consultations

 

Policy and Procedure Development and Review -  This service includes writing new policies and procedures as well as reviewing existing documents to ensure continued relevancy and conformance to CARF standards.  The review also includes identification of inconsistencies and redundancy. The frequency of reviews is determined based on the needs identified by the organization and as suggested by the CARF consultant.

 

Document Development and Review - This service includes report writing, document development, proof-reading, editing, and formatting of documents as well as annual updates to ensure conformance to CARF standards.  When an organization contracts for ongoing review of documents, the frequency of reviews is determined based on needs identified by the organization and as suggested by the our CARF consultant.  Many documents are required to be reviewed annually (e.g., program plans, strategic plan, risk management plan).

• Administrative Documents include:  The six administrative plans (i.e., Cultural Competency & Diversity Plan, Strategic Plan, Risk Management Plan, Technology & Systems Plan, Accessibility Plan, Performance Analysis & Improvement Plan); ethical codes of conduct; job descriptions; emergency procedure evacuation drill forms; grievance forms; requests for reasonable accommodations; quarterly billing audits; and other documents.

• Program Documents include: program plan(s); screening form; client orientation handbook and checklist; assessment form; treatment plan; transition plan; discharge summary; quality records review form; and other documents.

 

Quarterly Records Review - Due to lack of time and/or staffing, it is often difficult for organizations to conduct the required quarterly records review of a representative sample of open and closed charts (e.g., at least 10% of each). our CARF consultants are available to provide this on-site service on a quarterly (or more frequent) basis.  Written findings will be provided to managers for incorporation into training programs.

 

Survey Design, Administration, and Analysis - CARF-accredited organizations are expected to continually focus on the expectations of the clients, personnel, and other stakeholders. This includes soliciting, collecting, and analyzing input from clients and staff in order to implement changes in services to meet the identified needs. The leadership is also required to use the information in program, financial, resource, and strategic planning as well as for performance improvement and organizational advocacy. This component of continuous quality improvement can be challenging for many organizations. Our CARF consultants can simplify this task by designing and administering the surveys, providing a graphic analysis of the results, and write an outcome report. On-line and/or paper surveys can be designed to meet the unique needs of each organization.

 

Pre-Survey Preparation and Organization - Consulting services can be especially helpful in the month (and days) prior to the survey or re-survey.  We can assist in the organization of documents and other materials for easy access of the surveyors. When a surveyor cannot find the required information within a reasonable time, assistance is sought from the organization.  When samples of conformance to the standards cannot be produced by the organization, recommendations can be given. Contracting with a CARF consultant to prepare for the on-site survey can reduce the number of recommendations received.

 

Quality Improvement Plan (QIP) - In order to be useful, a good QIP contains interventions that effect actual and continuous change.  For example, a common problem for organizations is that treatment plans are often not consistently measurable, achievable, and time-specific.  An ineffective QIP action might state: “Direct-service staff will receive training about how to write objectives that are measurable, achievable, and time-specific.”  Although at “face value” this appears to be an effective intervention, training of staff often does not mean a direct translation to actual and consistent change. Contact us to learn more about how our CARF consultants can help write and implement effective QIPs.

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