Connections - 05.30.24

CARF Survey Preparation: Best Practices & Pro Tips

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CARF (Commission on Accreditation of Rehabilitation Facilities) accreditation can be a powerful asset for your disability service agency. It can help you enhance service delivery, expand your reach, and open doors to new funding opportunities.

In fact, CARF reports that accredited providers see on average:

  • 26% increase in persons served annually
  • 37% increase in conformance to quality standards
  • 37% increase in annual budget dollars

Achieving and maintaining CARF accreditation takes significant preparation and ongoing effort. In this article, we’ll share seven best practices that will help you on your CARF journey — whether you’re already accredited or preparing for your first survey.

Familiarize Yourself with the CARF Standards Manual

At 442 pages, the CARF Standards Manual isn’t exactly light reading. However, it’s essential for organizations seeking accreditation to be familiar with what’s inside.

The manual covers everything from accreditation policies and procedures to detailed standards that organizations must meet, requirements for documentation, and more. Think of it as your CARF Field Guide, maneuvering you through the accreditation process.

You’ll rely on it to help you identify specific standards that apply to your organization and ensure that your policies and practices align with CARF requirements. Just remember that CARF standards are updated annually, so you’ll need to spend some time familiarizing yourself with the most up-to-date version.

Establish Your CARF Preparation Team

Your CARF team will be responsible for overseeing the survey preparation process. This team will need to understand the CARF standards and in-depth knowledge of your organization’s operations and the programs you’re seeking accreditation for.

Knowledge of documentation, forms, and quality assurance processes will be necessary for the administrative side, while an understanding of person-centered practices will help your team on the program side.

Team members also need to be comfortable with communication, as they will be the ones liaising with CARF surveyors. They will also be the ones communicating with staff, clients, and the public through newsletters or updates about your CARF accreditation.

Centralized data management software like SETWorks can be a powerful tool for your team during the CARF accreditation process. It acts as a single source of truth, enabling multiple users to access and update information. This allows your team to work together efficiently on documentation, quality improvement initiatives, and other CARF-related tasks.

Provide CARF-Specific Training

While your CARF team will oversee survey preparation, all leaders and staff still need to be involved if you want to achieve and maintain accreditation. This is why it’s a good idea to offer training sessions on CARF standards and requirements to your entire organization.

Educate staff on their contribution to your organization’s CARF accreditation, from making sure documentation is complete and signed, to actively participating in quality improvement efforts and adhering to CARF standards in their daily work. This ensures that everyone understands why CARF accreditation is important and how their role is important in the process.

CARF standards are always evolving, so be sure to provide ongoing training opportunities to ensure staff stay updated on best practices. Not only will this help your organization meet the rigorous standards set by CARF, but it will ultimately lead to better outcomes for both your organization and the individuals you serve.

Develop Strong Organization Systems

To demonstrate compliance with CARF standards, organizations must maintain accurate, complete, and up-to-date documentation. This includes documenting program descriptions, policies, procedures, client records, and quality improvement initiatives.

A significant part of surviving your CARF survey is simply being organized.

“Being organized is very helpful. You already know all of the information, so that part is going to come easily — but make sure you have everything lined up so you’re not fumbling around looking for something,” says Kaci Reynolds, Director of Human Services & Operations at Learning Opportunities/Quality Works (LOQW), a CARF-accredited disability service agency in Missouri.

A robust data management system can provide your team with the tools they need to efficiently store and manage data and documentation, such as forms, signatures, activity records, and more. This ensures that the required information is readily available for CARF surveys and reviews, eliminating the need for manual searching through paper-based files or disorganized or disparate electronic systems.

Involve People Served in Your Quality Improvement Efforts

Continuous improvement is a core tenet of CARF. To that end, CARF encourages organizations to involve individuals receiving services, their families, and other stakeholders in quality improvement efforts. Their feedback and insights can provide valuable perspectives on service delivery and help tailor programs to better meet individual needs.

SETWorks’ Erik Nelson, a former CARF auditor, suggests implementing a simple yet effective practice: including a question on satisfaction with services at the end of each interaction. For example, individuals can be asked, “Were you satisfied with the services provided today?” This question can be included on a form that individuals sign after receiving services to capture their input in real-time. (If you’re using software like SETWorks, this can all be done digitally!)

Individuals can be invited to rate their experiences in their programs at their job sites, while employers who interact with the agency can be asked to provide feedback on their experiences, offering valuable insights into the effectiveness of the agency’s services.

By incorporating feedback mechanisms into daily interactions and program evaluations, you’ll create opportunities for individuals to voice their opinions, preferences, and concerns. This not only empowers individuals to play an active role in shaping the services they receive, but also fosters a sense of ownership and partnership between your organization and its stakeholders.

Conduct a Mock Survey

Mock surveys are a critical component of the CARF preparation process. Much like a dress rehearsal for a play or a scrimmage before a basketball game, these simulated surveys provide an opportunity for your organization to assess its readiness and identify areas that need improvement before the official CARF survey.

One of the primary objectives of a mock survey is to identify any gaps or deficiencies in compliance with CARF standards. This may include areas such as staff training, quality assurance processes, and documentation.

Having a software system that provides auditors read-only access can greatly enhance the effectiveness of mock surveys. By granting mock surveyors access to the same software system used by your organization, the mock survey becomes more realistic and closely mirrors the actual CARF survey process. Mock surveyors can navigate through the system, review documents, and assess data just as they would during the official survey, providing a more accurate representation of the organization’s readiness.

Additionally, mock surveys provide an opportunity for staff to become familiar with the survey process and practice their interactions with surveyors. Staff members may participate in mock interviews or role-playing exercises to ensure they are prepared to communicate effectively with surveyors during the official survey.

Engage with Surveyors During & After

CARF surveyors can be intimidating, but it’s important to remember that they are people too — and that they want to see you succeed.

You can help create a welcoming environment by briefing staff members on the importance of hospitality and professionalism during the survey. Encourage them to greet surveyors warmly, offer assistance as needed, and make them feel comfortable throughout the process.

Kaci emphasizes the importance of connecting with auditors during remote surveys, noting, “It’s a little more difficult during a virtual audit, but still try to figure out a way to connect.”

Of course, this will be much easier to do if you’re confident your files are organized, and you don’t need to scramble to locate information at the last minute. The right software tools can alleviate in-the-moment stress and contribute to smoother, successful interactions with surveyors.

By leveraging software solutions that provide secure access to documentation and facilitate organization and collaboration among team members, you can ensure that all necessary information is readily available and easily accessible. This not only demonstrates your organization’s commitment to preparedness, but also allows you to focus on engaging with surveyors in a positive and productive way.

Final Thoughts

Remember, the CARF preparation process is an ongoing effort that requires commitment, collaboration, and continuous improvement. By following the seven tips outlined above, your organization will more successfully navigate the CARF accreditation journey and maintain a high level of service quality and compliance with CARF standards moving forward.

Heather Janci is the Executive Consultant of Provider Strategy at SETWorks.