These standards effective July 1

These are the Commission on Accreditation of Rehabilitation Facilities’ (CARF) 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 3 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.

These standards 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 U.S. 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.

These have changed from previous manuals:

Criterion Four: Rights of Persons Served

Standard 24: One external inspection is conducted annually (previously twice every 3 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.