CARF Unaccredited Providers Training

2016 Standards

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This document revised April 2016.

Unaccredited Providers

Who is considered an “unaccredited provider”?

1. The organization receives more than $35,000, but less than $350,000 in revenue on an annual basis;

2. The organization serves more than 3 unrelated consumers;

3. Applies to any providers who intend to seek their own CARF accreditation, but have not done so at the time of the network survey

Legal Requirements

Provider Responsibility

Providers should be in compliance and provide documentation for all legal and regulatory requirements

for federal, state, provincial, county and city entities. The organization

should be aware of new and revised obligations.

Personnel Knowledge

Personnel should be knowledgeable of all applicable laws as well as policies on human rights and dignity of the persons served.

This information can be included in the employee handbook or through various media presented to all

personnel.

Areas of Legal Requirements

Provider should be prepared to answer questions regarding compliance in the following areas:

• Legal • Debt covenants• Regulatory • Corporate status• Confidentiality

requirements• Rights of persons served

• Reporting requirements • Privacy of persons served• Licensing requirements • Employment Practices• Contractual agreements • Mandatory employee

testing • Record Keeping –

Confidentiality & Security

Examples of Documents

• Reports from regulatory agencies• Reports associated with legal actions• Reports associated with contractual relationships• Policies & written procedures that address

confidential administrative records & the files of persons served

• Personnel policies manual/Employee handbook

Financial Planning And Management

Provider Responsibility

Providers maintain fiscal responsibility that is in accordance with their

mission, values, and annual performance objectives. Practices

adhere to established and accepted accounting principles and business

practices and covers daily operational costs and plans for long-term

solvency. If a provider handles funds of the persons served, it follows

applicable local rules and regulations.

Provider Responsibility

The provider can successfully demonstrate the following:

• Financial planning and management activities that support the services of the consumers

• Financial planning and management activities promote the success of the business

• Financial planning and management activities include: – The preparation of an annual budget– Fiscal policies and procedures, – Evidence of an annual review or audit by an individual

accountant.

Funds of Persons Served

If a provider takes responsibility for funds of persons served there are policies and procedures addressing the following:

• How consumer gives informed consent for disbursement of funds

• How consumer has access to records of their funds• How funds are segregated for accounting purposes• How provider ensures funds are used appropriately• How interest is credited to clients’ accounts• How accounts are reconciled monthly & provided to

clients

Examples of Documents

• Annual approved budgets• Written financial plans• Financial audits• Written procedures for handling the funds of persons

served• Account reconciliation documents

Health & Safety

Health & Safety

Providers maintain healthy, safe, and clean environments that support quality services and minimize risk of harm to consumers, personnel, and other stakeholders.

How does your organization accomplish this, aside from inspections and emergency procedures?

Competency-based Training

All staff must receive competency-based training upon hire and annually in the following areas:

• Health and safety practices• Identifying unsafe environmental factors• Emergency procedures• Evacuation procedures• Identifying critical incidents• Reporting critical incidents• Medication management• Reducing physical risks

Training Policy

A helpful first step is assigning responsibility of staff training to one person. A training policy should then be developed to include:

• Who will be trained• Who will conduct the trainings• What trainings will be performed• Where trainings will take place• The frequency of trainings• What are the objectives of trainings• How trainings are evaluated and documented

Procedures for tracking staff training should be implemented to ensure compliance in this area.

Examples of Training Types

Orientation & Education Sessions• Regularly scheduled and includes discussion,

information, Q&A, and identifying areas of concern/focus

Tabletop Exercise• Emergency Management group meets in

conference room setting to discuss responsibilities and plans of action

Walk-through Drill• Emergency team performs their emergency

response functions

Examples of Training Types

Functional Drill• These drills test actual areas and personnel

should evaluate the systems and identify problem areas

Evacuation Drill• Personnel walk the evacuation route & take notes

of possible problems

Full Scale Drill• Real-life emergency situation simulation

Emergency Procedures

Written emergency procedures and evacuation plans are required for the following:

• Fires• Bomb threats• Natural disasters• Utility failures• Medical emergencies • Safety during violent or other threatening situations

Emergency drills are conducted at least annually on each shift and include all types of emergencies (unless

otherwise stated by State or Contractual mandates). Documentation is available and reviewed for areas of

improvement.

Evacuation

Evacuation routes are easily accessible, posted and

understandable to persons served, staff, and visitors to the home.

Emergency Situations

During an emergency situation, there is immediate access to:

• First Aid equipment and supplies• Staff appropriately trained in first aid • Emergency contact information, medical histories

and medication lists for consumers and staff.

Written Emergency Procedures

Written procedures must address:

• Steps for a complete evacuation, including staff responsibilities, meeting places, alternative housing arrangements, etc.

• When evacuation is appropriate vs. shelter in place• Ensuring the safety of all persons involved• Accounting for all persons involved• Temporary shelter when applicable• Identification and continuation of essential services• Emergency phone numbers• Notification of appropriate emergency authorities• Location of resident emergency contact information

Test of Emergency Procedures

• Must be unannounced• Must be conducted at least annually on each shift and at each

home (follow State and Contractual requirements timelines).– A utility failure drill is completed on the morning shift, afternoon shift and

midnight shift. Ideally, they would not all be one the same day. • All types of drills should include at least one full evacuation

drill.– Additional drills can be alternative options, such as tabletop or walk

through. • Following the drill, areas for improvement are identified.

– Encourage staff and consumers by highlighting steps that were done well.

• Areas that need improvement are evaluated and documented in a plan of action. The plan should be implemented during the next drill.

Document, document, document!! Remember: If it isn’t written, it didn’t happen!

Resources for Emergency Preparedness

www.fema.gov www.disability.govwww.ada.gov/emergencyprepguide.htmwww.ready.gov

Critical Incidents

Policies and procedures must cover the prevention, reporting, documentation, timely debriefing and remedial action of the following types of critical incidents:

• Medication errors• Injury• Seclusion and/or restraint• Communicable disease/Infection control• Biohazardous accidents• Aggression or violence• Unauthorized possession of weapons• Wandering/elopement• Vehicular accidents• Abuse• Neglect• Suicide or attempted suicide• Sexual assault • Other incidents not previously identified

Critical Incidents

Critical incidents must be reviewed annually for:

• Causes• Trends• Actions for improvement• Results of performance improvement plans• Necessary education and training of personnel

related to prevention, reporting or documentation of incidents

• Prevention of recurrence• Internal and external reporting requirements

Incident Report Template

Infection Control

Policies and procedures outline standards for: • Preventing infection• Controlling the spread of infection if one is found• Training that covers infections and communicable

diseases. • Appropriate use of universal precautions

(handwashing, etc.)• How to address the procedures with staff and

consumers.

Transportation

Sites that provide transportation must have written policies and procedures that address safety of consumers and staff, as well as the maintenance of the vehicle.

Areas to cover: • Current and valid driver’s licenses for all approved

drivers• Clear driving records for all approved drivers• Insurance coverage• Safety features and equipment in the vehicle• Appropriate accessibility for consumers• Training for staff on transportation procedures• Means of communication while transporting• First Aid supplies• Maintenance records

External Inspections

Comprehensive health and safety inspections must:

• Be conducted annually (at minimum)• Be conducted by a qualified external authority• Generate a report addressing what was covered• Recommend areas of improvement• Actions taken to respond to recommendations

Areas are addressed in the Quality Assurance site reviews, as well as reviews by the Fire Department, Recipient Rights, Licensing, etc.

Self Inspection

Don’t wait for an external inspection to review your home!

• Twice a year, have staff on each shift complete a walk through of the home and identify potential problem areas.

• Develop a form that helps staff document what they’ve identified

• Don’t forget these areas: – Heating and cooling systems– Light fixtures, plugs, other electrical systems– Smoke detectors, fire alarm pull stations– Walk ways (inside and out)– Exits– Bathrooms– Food supplies– Storing chemicals– All vehicles used for transportation.

Examples of Documents

• Safety policies and procedures• Written emergency plans• External inspection reports• Self-Inspection reports

Human Resources

Human Resources

It should be evident that personnel are involved and engaged in the success of the provider and the persons served.

Staff that feel invested in the company are more likely to stay, reducing turnover rates and increasing quality of care.

Provider Personnel

Providers should employ and maintain enough trained staff to:

• Provide the services as written by the consumer’s treatment team

• Ensure consumers are safe at all times• Ensure coverage in the event of an unplanned

absence. A home should never be left short-staffed.

• Meet the established goals or mission statement of the provider.

Personnel Policies

Hiring the right staff is important to the success of the organization. To do so, it is important to have appropriate policies in place. Steps should be taken prior to hire and at regular intervals to ensure all requirements are met. Prior to Hire: • Background check Fingerprinting for licensed AFC homes• Immunization records• Drug testing (if applicable)• Verification of credentials

Annually: • Background check• Competency and skills training• Performance evaluations• Maintenance of required

immunizations (TB testing)

Human Resources

The provider:

• Demonstrates how they hire and maintain staff. • Hiring process, criteria for accepting applicant, disciplinary

steps, etc.• Identifies what qualities the ideal staff will possess.

How will they fit in with the other staff? What skills are needed for the consumers?

• Ensures staff receive the appropriate trainings to be successful in their job

• Develops policies and procedures that ensure compliance with all state, regional, local, and contractual guidelines for the delivery of services.

Your staff are crucial to the success of your business. Help them help you!

Orientation & Training

New Hire Orientations should be completed within 30 days of hire and should cover the following:

Annual refresher training should cover all of these areas as well.

• Confidentiality requirements • Professional boundaries• Customer service • Reporting suspected

abuse/neglect• Diversity • Rights of persons served• Ethical codes of conduct • Rights of personnel• Promoting wellness of persons served

• Safety of persons served

• Person-centered practice • Unique needs of persons served

• Personal privacy

Performance Management

• Job descriptions Signed at hires Reviewed annually

If changes to job duties occur, staff need to resign their job description

• Performance evaluations Based on job description Present in staff file Performed by direct supervisor with input from person

being evaluated Used to assess objectives from previous evaluations &

create measurable objectives for the following year. Performed annually

Examples of Documents

• Human Resource Policies and Procedures• Training requirements• New hire orientation

Rights of Persons Served

Rights of Persons Served

Providers are responsible for protecting and promoting the rights of the persons served. Providers need to identify and address unique and

specific cultural and diversity issues of the persons served in order to

ensure and support engagement in their programs or services.

Providing Rights Information

• The rights of persons served must be communicated in a way that is understandable to consumers.

• Rights information must be given prior to the start of service delivery or at the beginning of service delivery and annually

• Rights information must be available to persons served at all times

Rights of Persons Served - Cont.

Consumer’s have the right to privacy and confidentiality. They also have the right to access their information at any time. The provider must have policies promoting:

• Confidentiality of information• Privacy• Freedom from abuse, neglect, retaliation, humiliation,

financial or other exploitation• Procedures for how consumers can obtain their records• Informed consent or refusal or expression regarding:

service delivery, release of information, concurrent services, composition of service delivery team, involvement in research

• The unbiased investigation and resolution of alleged rights violations

• Availability of other legal rights (advocacy groups, etc.)

Informed Consent

What does informed consent mean?

Appropriate permission must be obtained prior to starting any type of health services. Consent must provide information about the treatment to be received.

Consent may be obtained from the consumer, legal guardian, or other legally authorized individuals.

Documentation of consent must be present in the case record.

Release of Information

Must have policies/procedures describing how information will be transmitted to other individuals and agencies

• A release is required for anyone that does not have a legal right/need to view the information (refer to HIPAA guidelines)

Release of information forms identify at a minimum: Name of person served Content being released To whom information is being released Purpose for release Date it was signed Date or condition the release expires Information on how authorization may be revoked Signature of person legally authorized to sign the release

No release, no information!

Rights Complaints

The provider implements written policies and procedures in which persons served may formally file a complaint and that specifies:

• The action will not result in retaliation in any manner• How efforts will be made to resolve the complaint• Levels of review, including external• Time frames that are adequate for prompt

consideration and result in timely decisions• Procedures for written notification regarding actions

to be taken• The rights of each party• The responsibilities of each party• The availability of advocates or other assistance

Complaint procedures should be readily available and understandable to persons served.

Complaint Resolution

The provider maintains ongoing records of formal complaints, investigation results and final outcomes.

• Reviews are completed annually to identify trends, areas of improvement and actions to be taken.

Examples of Documents

• Consumer Handbook• Cultural Diversity Plan• Grievance Policies• Chapters 7 and 7a of the Michigan Mental Health

Code

Accessibility

Accessibility Plan

The accessibility plan is a tool used to outline non-urgent actions that need to be taken to improve the safety or quality of services within a home.

• Can be used to identify future home improvements that may be too costly for the present year

• Helps the provider assess the overall wellness of the business.

• Consider it a long-term road map for improvement

Accessibility Plan

Areas to include in your accessibility plan:

• Architecture• Environment• Attitudes• Finances• Employment• Communications• Transportation• Community integration• Any barriers identified by persons served,

personnel, other stakeholders• Timelines for removal of identified barriers• Actions for removal of identified barriers

Accessibility Plan Example

Accessibility Status Report

All barriers should be addressed in a status report which must:

• Be in writing• Be prepared annually• Include progress made in removal of identified

barriers and areas of improvement

Examples of Documents

• Meeting minutes• Written accessibility plan• Identification of barriers• Annual accessibility status report• Requests for reasonable accommodations

CARF Resource

CARF has developed a workbook to assist unaccredited providers with the required standards.

*** Visit the Provider Portal to obtain a copy of the 2016 Standards Workbook for Unaccredited Providers and other CARF documents or go directly to them through these links.

2016 CARF Standards Workbook for Unaccredited ProvidersCARF Standards Table of Contents for Unaccredited ProvidersCARF Operational TimelinesEmergency Drill Workshet

Additional CARF Links:

Monthly Incident Report Tracking LogAnnual Incident Report Tracking LogRecipient Rights Tracking LogGrievance Tracking LogAccessibility Plan Template