These CARF standards take effect July 1

Some standards new, some have changed

Not only are CARF’s new manuals blended to be useful to each type of rehab facility, but there also are new standards in each area. Following are the standards (copyrighted by CARF in the 2003 Standards Manuals) that are new for every type of facility:

Criterion Three: Information Management and Performance Improvement

Standard 12: For business improvement, information is collected and analyzed from the following: strategic planning information; financial information; accessibility plans; resource allocation; surveys; risk analysis report; technology analysis; environmental health and safety reports; and field trends.

Standard 15: To support information management and performance improvement activities, the organization has a written technology and system plan that includes hardware, software, security, confidentiality, backup policies, assistive technology, disaster recovery preparedness, and virus protection.

Criterion Six: Human Resources

Standard 37: The organization demonstrates recruitment efforts, retention efforts, and identification of any trends in personnel turnover.

Standard 39: Annual performance management includes: job description reviewed and/or updated annually; promotion guidelines; job posting guidelines; annual performance evaluations for all personnel directly employed by the organization.

Criterion Eight: Legal Requirements

Standard 45: During the CARF survey, the organization provides for review of all reports from legal actions, regulatory agencies, and contractual relationships.

Standard 46: The organization provides a synopsis report on any of the following that have occurred within the last three years: litigation; allegations of wrongdoing; malpractice; and violations of the codes of ethics.

Criterion Nine: Financial Planning and Management

Standard 53: There is evidence that the organization has established and maintains fiscal policies and procedures, including internal control practices.

Following are the standards that are new for some organizations:

Criterion Three: Information Management and Performance Improvement

Standard 16: If Internet access to the organization’s services is provided, the organization provides for security of personal information; alternative access formats; accessibility and accommodations and a user-friendly interface; on-line information 24 hours a day, 7 days a week; personnel to provide instruction and guidance to accessing services provided by the organization; and connections or links with local service providers or affiliates for personal contact and information.

Criterion Seven: Leadership

Standard 44: An organization in the United States receiving federal funding demonstrates corporate compliance through a formal resolution on corporate compliance; written designation of a personnel member to serve as the primary point of contact for monitoring and reporting corporate compliance; procedures to guide personnel in responding to subpoenas, search warrants, investigations and other legal actions; and provision of initial and ongoing training on billing and coding procedures.

Criterion Nine: Financial Planning and Management

Standard 54: If the organization bills for services provided, a quarterly review of a representative sample of records of the persons served is conducted.

Following are the standards that have changed from previous manuals:

Criterion Four: Rights of Persons Served

Standard 24: One external inspection is conducted annually (previously this was done twice every three years) that provides: evidence that all locations owned, leased, operated, or rented by the organization or donated to the organization have been inspected by a designated compliance/safety officer; a report that identifies the areas inspected; recommendations for areas needing improvement; and an action plan for improvements to be made.

Criterion Five: Health and Safety

Standard 32: The organization defines a system to report critical incidents that includes the following (this list of incidents is new) as applicable: medication errors; incidents of seclusion or restraint; incidents involving injury from equipment, machinery or vehicles; communicable disease; infection control; violence or aggression; sentinel events; weapons; elopement and/or wandering; transportation; biohazardous materials; licit or illicit substances; and other areas as required.

Need More Information?
  • Christine MacDonell, Managing Director of Medical Rehabilitation and Emerging Markets, CARF, 4891 E. Grant Road, Tucson, AZ 85712. Telephone: (520) 319-3024. E-mail: cmacdonell@carf.org. Web site: www.carf.org.
  • Bonnie Breit, President, BRB Consulting, P.O. Box 515, Media, PA 19063. Telephone: (610) 566-2828. E-mail: bonnie@brbconsult.com. Web site: bonnie@brbconsult.com.