Accreditation Maintenance: Key to Continued Achievement

Congratulations! You’ve worked hard to earn accreditation, which affirms that you meet designated national industry standards, and that you are focused on supporting your staff, organization-wide continuous improvement and most importantly, supporting positive outcomes for those in your care. You and your colleagues celebrated the achievement and have now returned to your daily routines with renewed vigor.

It’s easy to forget, however, that the countdown to reaccreditation begins the day you achieve your goal. Depending on the accrediting body, your organization will go through a reaccreditation review every 3 or 4 years and you will be required to submit annual accreditation reports. Complicating matters, accreditation standards are generally updated annually.

Here’s the good news:  With an accreditation maintenance plan – your organization can and should experience the initial accreditation effort as the ‘heaviest lift’.  In other words, by taking a few simple steps, reaccreditation should not be as time consuming or detailed as the initial accreditation process.

Maintenance can be as easy as a periodic check in or a more thorough review of standards.  Either way, the goal is to ensure the appropriate documentation is gathered along the way, rather than scramble to get everything together when the deadline approaches

Of course, every organization has different needs, so AG has developed a few different Accreditation Maintenance Plans to meet those needs.  Some agencies find that a few hours of focus per quarter at their discretion is enough to allow questions to be answered and updates reviewed, others prefer a more scheduled check in, and standards updates that we track on their behalf.  Whatever the need, we have found that given the time and resources spent achieving this initial distinction, working to proactively maintain accreditation for the long term will not only continue to strengthen your organization’s operations but it will improve services as it makes the reaccreditation process more efficient and effortless.

The bottom line:  The key to continued achievement is to establish a pattern of maintenance in your organization with continued focus on the overall implementation of accreditation standards, including client safety, risk management and performance and quality improvement.

Here are some ideas to consider when thinking about accreditation maintenance:

  • An effective and sustainable performance and quality improvement program must be clearly demonstrated as an ongoing part of the agency’s operations from year to year.
  • Best practices include sharing quarterly and annual performance summary reports with staff and board members. Annually sharing key performance metrics with various stakeholder groups to demonstrate increased transparency and open communications should also be considered.
  • An annual calendar of accreditation milestones helps keep your organization on track for reaccreditation and provides a solid review of the progress you’ve made to proactively prepare for the process.

If your organization needs help establishing or maintaining any of the accreditation standards or implementing ideas noted above, Accreditation Guru can help.  We place an emphasis on performance and quality improvement, risk management, annual reporting requirements, and updates to standards as they pertain specifically to your organization.  Check out our plans here or contact us directly for more information.

8 Questions to Ask When Starting on the Road to Accreditation

I am often approached by people who are just beginning on the road to national accreditation and have no idea where to start. Our conversations tend to follow a similar path, including which accrediting body they should work with (read here for 10 Steps to Selecting an Accrediting Body).

As part of our conversations, I often ask them questions to consider when planning for accreditation. I thought it would be helpful to share them with you here:

  1. Do I know how to best “sell” accreditation to my board of directors and staff? (click here for a video with tips) https://accreditationguru.com/how-best-sell-accreditation/
  2. What policies and procedures need to be written or updated to map to both the accreditation and licensing standards and current operations?
  3. All staff trained on procedures pertaining to emergency response preparedness and infection control and safety?
  4. Would it be helpful to conduct a mock survey? If so, who will complete it?
  5. Do we have documented stakeholder input in our quality improvement and risk management efforts? Do we even have quality improvement and risk management programs in place??
  6. Do our facilities need improvements to pass an accreditation survey? Yes, facilities are still reviewed during a virtual survey.
  7. Who will be our Accreditation Coordinator and who will be part of the Accreditation Team?
  8. Do we need assistance from an outside consultant to bring in expertise with our selected accrediting body, help streamline the accreditation process and provide much needed project management? Accreditation Guru is here to help!

Wishing you all the best on your accreditation journey! Please contact us with any questions or to explore assistance options.

The Final Deadline for Implementing FFPSA is One Year Away – Here’s What You Should Know

In 2018, the Family First Prevention Services Act (FFPSA) mandated that Qualified Residential Treatment Programs (QRTPs), in part, must be licensed by their state and achieve national accreditation to receive Title IV-E funds following the initial two weeks after a child enters their care.[1]  The time originally allocated to submit program plans was two years with the potential for taking a two year delay.

Although agencies and states have evolved in their understanding and communication of many aspects of the federal bill, presently only twelve states, plus the District of Columbia and two tribes have submitted Title IV-E Prevention Program plans, which indicates when the state intends to implement FFPSA. Additionally, we now find ourselves just one year out from the final implementation deadline of October 1, 2021.

From an agency accreditation perspective – this means that while there is still time to become accredited, it will need to be done with a consistent effort, focus on efficiency, and a continuous eye on timing. 

In general, it takes 12 to 18 months to prepare for national accreditation; depending on the original state of readiness and the accrediting body selected. If you have not yet discussed the subject within your organization, now is the time.  Below, we have compiled some facts and important steps you can and should be taking now if you wish to become a QRTP.

FACT:  TIMING IS EVERYTHING: This is a crucial piece to understand and communicate within the organization.  When an agency’s board and staff understand the time constraints that you are working within – the probability of quicker responses, approvals and/or comments will increase.

Important Steps

Select an Accrediting Body –The accrediting bodies approved under FFPSA are: CARF International (http://carf.org), Council on Accreditation (COA) (https://coanet.org/) , The Joint Commission (https://www.jointcommission.org/), or other accrediting bodies approved by the Department of Health and Human Services (HHS).[2]   We have a helpful chart that compares the three accrediting bodies.  Contact us for that and/or for input on which accrediting body would be best suited for your organizations’ needs.

Know Your Baseline – Benchmarking your organizational starting point against the expectations of accreditation will allow you to focus more time on the less developed aspects of your plan.   It will also help anyone who is working with you to start with this information and move you forward from there, rather than taking the time to fact find on your behalf.  One way to establish your readiness for accreditation is to take our Free Readiness Assessment.  

FACT: BUDGETING NOW WILL SAVE TIME LATER:  Plan now to secure budgetary allocation with the board’s approval for the entire amount ahead of time.  As the process can take a year or more to complete; accreditation could theoretically be spread over two budget cycles and you may be tempted to push off getting part of the total spending approved until the second budget cycle. However, this simple task can literally add weeks to the project – when you need to stop for approvals and get payments routed for signatures before proceeding to next steps.

Important Steps:

Include Benefits in the Proposal:   You are already aware of the importance of understanding all accreditation costs up front, but clearly identifying and including the benefits to the expenditure in your proposal when routing to key decision makers is also crucial.  To ensure you have a clear outline of benefits of accreditation, you can review our articles, blog posts and videos that can help clarify the points that make the most sense for your organization. Go here and type in “benefits” in the search area to pull up relevant info.

FACT: BOARD AND STAFF BUY-IN IS KEY:  Preparing staff and board members for the accreditation process is one of the most overlooked but (in our experience) one of THE most valuable investments you can make prior to starting the process.  Organizations often think that one person will lead the charge on finding a team and holding the team accountable to the tasks at hand.  But this is often done at the expense of day-to-day responsibilities.  By clarifying not only what the accreditation process entails but why it is happening – more people will have a sense of the timeliness involved and be motivated to help.

Important Steps:

Plan for Getting Buy-in as an Event.  Appointing one person, or team of individuals (perhaps an accreditation communications committee) to be the accreditation point of contact for agency staff and other stakeholders can assist in making the accreditation process an enjoyable one for all. Allowing a bit of latitude can be beneficial and a bit of fun, for example, kick-off events, holding an accreditation fair to exhibit new accreditation policies and procedures to one another, trivia contests, accreditation field days, team picnics, etc. There are people who enjoy accreditation, so find them and utilize them!

Consider a consultant.   Achieving accreditation is an involved process that will require your employees to spend less time on their day-to-day responsibilities. To ensure efficient time management, consultants go beyond providing training functions and serve as sounding boards to answer questions from staff so no one is spinning their wheels or getting lost down a rabbit hole trying to figure out what the accreditation standards mean.  Contact us to start a conversation on how we can help you get this done on time and budget.

With the FFPSA deadline looming, impacted organizations should begin the accreditation process now to get ahead of the influx of other providers seeking to become accredited and have enough time to thoroughly complete the necessary work. Once the process begins, effective project management and support from leadership will help ensure that accreditation activities stay on track despite other priorities that may arise.

Accreditation Guru assists organizations in creating a customized accreditation timeline based on its strategic planning and provides support along the way to successfully meet each milestone.  A accreditation calendar provides a visual tool to keep leadership and staff focused for an efficient process.

[1] Public Law 115-123,section 50741 (page 190); available at: https://www.congress.gov/115/bills/hr1892/BILLS-115hr1892enr.pdf

[2] Two additional accrediting bodies have been approved for QRTPs since the passing of the law: Educational Assessment Guidelines Leading toward Excellence (EAGLE) (http://eagle1.org/) – a faith-based accrediting body – and Teaching-Family Association (https://www.teaching-family.org/)


For more information or questions about the contents of this article, please write or call Jennifer Flowers @ Jennifer@AccreditationGuru.com / 212.209.0240.   This post contains original content and was written for Accreditation Guru, Inc. Use of this copy is permitted with credit and reference within the same body of copy to Accreditation Guru, Inc.

BEYOND BEHAVIORAL HEALTH: The Joint Commission Expands Its Profile in Child Welfare.

The Joint Commission’s behavioral health care accreditation program has undergone some transformative changes in recent months.  These changes are expansive in their consideration for adoption, family preservation, foster and kinship care and child protective services.  The Joint Commission is also leveraging best practice, federal regulation and the utilization of terms familiar to human service providers to enhance their efforts.

Recently, Julia Finken, BSN, MBA, CPHQ, CSSBB, Executive Director of Behavioral Health Care and Human Services accreditation program, expanded on the motivation behind the development of the new/revised standards for child welfare agencies.  “The Joint Commission wants to make sure that our child welfare accreditation is contemporary, relevant and supports child welfare agencies in delivering the highest quality of services for this vulnerable population of children and families,” said Julia.

To better reflect Joint Commission accredited organizations providing social services in community settings, services for people with intellectual/developmental disabilities and foster care for children and adolescents, the name of The Joint Commission’s behavioral health care accreditation program has changed to Behavioral Health Care and Human Services accreditation program.  Additionally, new and revised requirements for child welfare services and language changes to standards have been created and will become effective on September 13, 2020.

An extensive literature review, a public field review, several pilot surveys, and guidance from an advisory panel of subject matter experts from the child welfare field were provided.  Also contributing were a standards review panel of clinicians and administrators who gave a “boots on the ground” perspective and insights into the practical application of the proposed standards.

Accreditation Guru’s founder and CEO, Jennifer Flowers, was invited to participate in the development process as a member of the standards review panel.  “I was honored to be included in shaping the future of Joint Commission standards for child welfare service providers,” said Jennifer.  “During the review, I often reflected on the impact (positive or not) of the proposed standards on current and former clients’ operations and service delivery and how the standards may be interpreted.”

A large body of work in both qualitative and quantitative research revealed the importance of an accreditation process with a social service model and humanistic approach tailored to specific child welfare service lines.  Also notable was the identification of specific leading practices in the child welfare industry. The child welfare services provider research also indicated that the most important standards in the child welfare industry revolved around case management and service coordination.

As a result, 74 new and 12 revised elements of performance will be incorporated into Joint Commission-applicant and accredited child welfare agencies as well as revised language in existing standards to be more inclusive of human services (https://www.jointcommission.org/standards/r3-report/r3-report-issue-27-new-and-revised-standards-for-child-welfare-agencies/).

The Joint Commission is offering a free day of virtual learning focused on the new enhanced Child Welfare accreditation. Register at:  https://www.jointcommission.org/resources/news-and-multimedia/webinars/2020/08/virtual-learning-day-for-behavioral-health/

Accreditation Guru’s expert consultants are available to determine applicability of these new/revised requirements to your organization’s services and to help you implement these new/revised requirements.


For more information or questions about the contents of this article, please write or call Peggy Lavin @ peggy@accreditationguru.com.   This post contains original content and was written for Accreditation Guru, Inc. Use of this copy is permitted with credit and reference within the same body of copy to Accreditation Guru, Inc.

Accrediting Bodies Offer New Ways To Continue Accreditation Efforts

(Re)accreditation is often an important component of an organization’s strategic planning.  For congregate living facilities (residential or group home settings) seeking reimbursement under Title IV-E as a qualified residential treatment program (QRTP), achieving or maintaining accreditation by an approved accrediting body is a required component of strategic planning.    

Likewise, (re)accreditation may also be required to obtain/maintain license/certification for an organization to operate/deliver services or for reimbursement through commercial or public health insurance.   

Fortunately, all three accrediting bodies have found efficient and meaningful ways to continue their work so organizations can continue in their accreditation efforts.  

CARF International:   

CARF’s Digitally Enhanced Site Surveys have been occurring since mid-May and CARF advises Accreditation Guru (AG) that this process has been met with very positive responses from its programs.   

Council on Accreditation (COA) 

Effective July 1, COA is providing virtual options for site visits and will work with each organization to determine most appropriate option.  Having an onsite presence is part of some of the COA options. 

The Joint Commission:  

The virtual survey option offered since June by The Joint Commission for behavioral health care accreditation of Opioid Treatment Programs (OTPs) will be expanded to include a virtual survey option for organizations meeting Joint Commission eligibility requirements (including certain technology capabilities).  On-site survey is also an option for some organizations in geographic areas identified as low risk by Joint Commission leadership – details here. 

All three accrediting bodies are asking organizations to confirm with applicable federal/state/local regulators that virtual site visits/surveys are acceptable.  (AG has been advised by The Joint Commission that the US Administration of Children and Families has approved virtual surveying for Qualified Residential Treatment Programs (QRTPs) if accepted by any related state regulatory authority).   

Accreditation Guru assists organizations in creating a customized (re)accreditation timeline based on its strategic planning and provides support along the way to successfully meet each milestone.  A re(accreditation) calendar provides a visual tool to keep leadership and staff focused for an efficient process. 

If you have questions on (re)accreditation please contact us – 212.209.0240 or email info@accreditationguru.com

Tamarack Center CEO, Tim Davis and the Importance of Accreditation

Accredited by The Joint Commission since 1986, the Tamarack Center provides top-tier residential psychiatric treatment to adolescents in Spokane, Washington.  In addition to a web page devoted to “Accreditation and Licensing” on their site, they also display the Gold Seal of Approval logo from The Joint Commission. Recently, Tim Davis, CEO at Tamarack Center expanded on the importance of accreditation and its significance to his organization.

Tamarack achieved accreditation because their contract with the state required it. Though the process and its aftermath helped turn Executive Director Tim Davis into a strong advocate for the benefits of being accredited.

In this interview with Accreditation Guru, Tim contends that accreditation limits liability, attracts top talent and convinces parents to trust their children’s care to Tamarack. You may even be able to negotiate a discount with your insurance carrier.

What are some of the prime benefits of accreditation?

With the world being so litigious, you want to limit liability. You don’t want to be out there without some form of accreditation, which is a statement about how you do things. Plus, you’re regularly reviewed by outside parties on a continuous improvement plan.

Over the last 35 years I’ve seen a lot of people who never thought about these things. Now realizing it’s not only smart to do, but it also offers huge protection in any disagreement or litigation.

The legal protection is so important, especially in [the behavioral health] world. Something bad can happen at any time, be it a successful suicide, a sexual assault, running away, being harmed or harming someone.

Typically, the basis of any lawsuit is that the institution had no idea what they were doing. From the parental perspective, it’s “I left my child in their care and they have no idea how to handle my kid.”

When it gets to that point, attorneys say that it’s helpful to show that you’re adhering to accreditation standards over a period of time. That you’ve thoroughly covered your processes and you’re dedicated to running the place with that in mind. You can even show surveys where they found deficiencies and you took steps to correct that issue as an ongoing daily process.

It ensures that you’re paying attention to the environment of care and ethical standards. Then, you have a much stronger defense. Otherwise, it’s he-said-she-said, back and forth. I value this kind of protection.

To what do you attribute a rise in knowledge about accreditation?

There’s a little more awareness each year. People go on the web and begin to understand. Now, insurance companies are spreading the word and getting more involved.

Really? That’s interesting. Do insurance companies offer discounts to organizations that are accredited?

[Laughs.] I’ve never heard of that, but they should.

[Accreditation Guru note: Some liability insurance companies will take into account accreditation when determining the cost of liability insurance for a residential program because they view accreditation as an acceptable risk reduction strategy. The cost saving may be the result of a direct discount on premiums or due to having accreditation status gives the program a better rating that results in a reduced rate.]

You mentioned that you operate in a distinct environment.

Over the years, there have been a lot of conversations about residential care for kids. There are a lot of unlicensed, rogue programs that certainly aren’t accredited who think they know how to heal problem kids.

A lot of boot camp style centers got a lot of publicity on Dr. Phil and NBC News, but the residential treatment centers that are accredited can’t do things that people consider to be rogue. They made a commitment to do just the opposite, with a set of agreed upon standards.

We talk about assessment and such a key part of anything you do is to try and understand what the conditions are and what your organization can do for them. I tell parents that we’re going to do a mountain of assessments and you can have access to all of this and decide on the course of treatment.

The rogue operators say “just let Johnny stay with us two months and you’ll get a different kid back.” Are they going to do legitimate service to families? One way to do that is to adhere to an agreed upon set of standards.

Why don’t more residential treatment centers become accredited?

It’s not an easy thing to do and it represents an expense. But our organization considers it money well spent.

When I talk with non-accredited places, I realize how fortunate I am. I’ve got a high bed rate, top-flight staff and a high level of safety. Other places may have a lower bed rate and take kids because they need to fill the beds, but they may not be equipped to deal with suicidal or psychotic kids and if they have three people with a high school equivalence working the floor and a psychiatrist who comes in two hours a month, that’s a nightmare.

Sometimes, nonprofits can be naive about the mission, thinking that all you need to take care of disturbed kids is “if you hug ‘em and feed ‘em, they’ll get better,” but that’s where accreditation comes in. It adds a level of seriousness and professionalism that you can’t get anywhere else.

My biggest battle with the state is that our accreditation defines the scope of care – we have 16 beds and we’ve decided that there are certain types of kids we can’t serve and the state goes crazy when we declare that a placement might be out of our scope of care, which is the foundation of our contract.

Nonprofits that don’t define their scope of care get into a tremendous mess when they take people for whom they can’t provide appropriate services. I talk with people who are licensed, including nurses and doctors and tell them that they never want to work in a place that is not accredited because it provides a bit of a safety net for your license if something goes haywire. And it will.

In behavioral health they can come after you, but in most cases you will be protected because the heart of the argument is “what kind of place is this?” Is it a ragtag outfit or a professional medical environment? All you need to know is that it’s accredited.

There’s always going to be resistance to accreditation in the beginning due to the amount of work. And yeah, it’s more work, but it’s not insurmountable. With The Joint Commission, there are many ways you can meet a standard, they’re not dictatorial. Accreditation gives you and your staff accountability in this highly unpredictable, litigious field of work.

Does accreditation help with your marketing? Do parents know about it?

We’re small and we’re almost always full, so we don’t do much marketing. But we do speak with parents all the time who ask “why should I leave my child here? What can we expect?” And accreditation is a big part of that conversation.

I actually show them The Joint Commission manual and tell them “here are the things for which we are held accountable” and I let them spend as much time as they want asking me about our internal processes, making sure that something in the manual is happening.

It’s a big part of helping parents feel comfortable putting their child here. They know that there is some system in place that we have been doing for years and our standards of care are at the same level as the best providers across the country. It’s comforting for them.

Spokane is a small place, so if something bad happens, people talk about it and if it turns out that a place has no accreditation, I use it as an opportunity. I tell people that I have this written road map about how to care for people ethically and efficiently. Then, outside people come in and put you under the microscope and say “are these guys doing this or not?”

We’re licensed in Washington state five ways and the license reviews and audits are really specific. They’ll look at the fridge or run a white glove over something, but they’re not getting the full picture of care. Accreditation does.

So when there’s an incident in town, you spring into crisis coordination mode?

People inevitably ask “how could that happen?” The worst answer you can give is that the system broke down. If you can answer that a person made a mistake or willfully performed a bad act, people are more understanding because as humans, those things can happen. The public is less understanding of people who run something where the system allows a mess.

You had no background in accreditation when you took over at Tamarack, right?

I was a clinical guy and knew little about the management side of nonprofits, but The Joint Commission laid out what I had to do if I’m managing the thing properly.

Like everything, there was a learning curve, but the key – when I look back – is to understand the philosophy of each standard. What’s really important is that once you get this, then the whole accreditation process makes ten times more sense.

You ask yourself, “is it really important to do that?” If the answer is no, then ask, “why not, if that’s the standard?” You’d be amazed how many times we ask “is it important to do that?” and at first people might say “that’s stupid, we don’t need that.” And then, inevitably, you look around the table and people are shaking their heads saying “yeah, this makes sense.”

For new young management like me, the standards themselves served as a mentor or guiding force.

To learn more on how achieving accreditation can help elevate your organization, call us at 212.209.0240 or email Rocio@AccreditationGuru.com for assistance in setting up a commitment-free phone call with our CEO, Jennifer Flowers.

Pine River Institute CEO, Vaughan Dowie, Sits Down with Accreditation Guru

Located near Shelburne, Ontario, Pine River Institute is a residential treatment center and outdoor leadership experience for youth 13 to 19 years old struggling with addictive behaviors and often other mental health issues. Shelburne is approximately 60 miles northwest of Toronto.

Pine River Institute’s decision to apply for and maintain national accreditation was based solely on internal drivers – commitment to quality and safety and to increase parents’ confidence.

Why did Pine River utilize a consulting service?

Eight or nine years ago, Pine River Institute was getting ready for its Council on Accreditation (COA) first re-accreditation on-site survey and the key staff involved in the original, initial accreditation process was no longer with Pine River Institute. Pine River Institute’s CEO, Vaughan Dowie, met Jennifer Flowers, Founder & CEO of Accreditation Guru, Inc. at a COA training event in New York City.

During a conversation with Jennifer that he learned that there were accreditation consulting services available for organizations like Pine River Institute.

Why did Pine River engage Accreditation Guru?

Knowing that the pre-work is most important and wanting good support, he engaged Jennifer. He selected Accreditation Guru, Inc because he found Jennifer to be very open to help; very knowledgeable; and, she had a good understanding of what was being asked of Pine River Institute by COA.

What was Pine River’s experience with Accreditation Guru like?

Vaughan’s experience with Accreditation Guru was very positive. With Accreditation Guru’s support, Pine River Institute was able to successfully navigate the accreditation process. Jennifer was always available; always able to answer questions; always came through! Her approach was down to earth with realistic answers. In fact, his initial experience led to “repeat business” and Pine River Institute has partnered with Accreditation Guru several times for COA re-accreditation. Each time, less support was needed as Jennifer helped PineRiver Institute to learn to “walk by itself.

Uniqueness of Pine River

Pine River Institute is unique in that it provides a “traditional” residential as well as an outdoor wilderness therapeutic program. Although both programs involve risk and exceptional risk management, the wilderness program has greater risk.

All programs are somewhat unique and special, but accreditation is as close as you are going to get to a third-party oversight/as close as you can get to a proxy for quality. Parents must have faith in an organization keeping their children safe. Other quality indicators (such as testimonials) can only go so far. When you are placing your child in a place where you know no one, you want some assurance of safety and quality.

Pine River Institute has 36 beds with a current waiting list of 200 children. If parents cannot wait for a Pine River Institute opening and ask Vaughan for advice on selecting another organization, he always advises the parents to only consider accredited programs. In order to be a “grown-up” you need to be nationally accredited.

To learn more on accreditation consultation, call us at 212.209.0240 or email Rocio@AccreditationGuru.com for assistance in setting up a commitment-free phone call with our CEO, Jennifer Flowers.

Accreditation’s Significance in Time of Crisis

Since late February 2020, child welfare agencies and behavioral health care organizations have been forced to focus on two critical functions – infection control and emergency management. Depending on the services provided and location of the organization, providers have been forced to change their operations in ways that include having all employees work remotely, provide telehealth services or even “closing the gates” and delivering residential services without people going on or off the property.

In these trying times, the framework provided by implementing national accreditation standards certainly helps service providers better manage the necessary pivot in operations and service delivery in this time of crisis.

Accreditation Standards – Detailed Plans and Strategic Safety Net

Accreditation standards that address risk prevention and management, infection prevention and control, performance and quality improvement, technology and information management and staff training are all being put to the test these days.

Effective risk management controls include, but are not limited to, emergency response preparedness. An accredited agency is required to have a written disaster plan for evacuation and relocation of staff and clients, parent-child reunification following a disaster, as well as specific plans to meet the needs of individuals with disabilities and other special needs during emergencies. The organization must also address coordination with governmental authorities and emergency responders. Further, staff needs to be trained on how to respond to medical threats and emergencies and how to handle potential safety risks they may encounter on the job.

Accreditation (maintenance and preparation) guides an organization through a thoughtful, structured and planned process to create an infrastructure for risk management and performance improvement that can be seamlessly implemented during times of crisis like this one.

The accreditation process also helps organizations review and strengthen their policies and practices through compliance with national standards of care. This includes creating processes for gathering and using data for continuous improvement of the quality of the services provided. It is not enough to collect and analyze data related to outputs such as the number of clinical sessions provided or the total number of clients served, but they also must identify, observe and measure the effects of a program’s services on clients.

“Plan and procedures for disaster readiness are a lived concept for CARF-accredited organizations. The readiness mindset of our programs has helped organizations and their staff to transition services to better support children and families during this pandemic.” – Leslie Ellis-Lang, MMFT, Managing Director, CARF Child and Youth Services *

Technology-Based Service Delivery – AKA Telehealth

Due to the pandemic and resulting COVID-19 funding legislation that now expands coverage for telehealth services for Medicaid and Medicare beneficiaries, a vast number of service providers were given the opportunity to make a seemingly overnight shift to employees working remotely and providing telehealth services.

The existing accreditation standards in place that address the management of technology-based service delivery allow companies to reference their strategic plan and immediately embrace the full-time use of this technology.

Any accredited organization that engages or plans to engage service recipients in technology-based service delivery needs to develop policies and procedures to guide telehealth service delivery to address privacy and security measures. They must also assess the appropriateness of technology-based service delivery for each individual and monitor effectiveness of using this model.

Accreditation standards further address competency-based training for personnel on the use of equipment and software, privacy and confidentiality issues, and recognizing and responding to emergency or crisis situations from a remote location.

While many organizations may not have developed a detailed pandemic response plan, wouldn’t it have been helpful to have already addressed and planned for the use of telehealth services and having employees work remotely under the framework of accreditation standards?

Accreditation Drivers

“Accreditation is not just a box to tick and this is even more apparent during times of crisis,” says Jody Levison-Johnson, President and CEO, Council on Accreditation (COA). “COA has standards that address key preparedness and response issues. These fall under the broad standards categories of human resources management, safety and security, and emergency preparedness – all of which are critical during times of crisis.” *

The three major accrediting bodies for human service organizations (CARF International Council on Accreditation and The Joint Commission) research and develop their unique set of accreditation standards that address a commitment to helping child welfare and behavior health care organizations provide safe and high-quality care, treatment or service. Applying the standards often leads to an increase in consumer confidence in service delivery. Read “Increasing Consumer Confidence Through Accreditation“.

“(The Joint Commission) recognizes the challenges behavioral healthcare organizations are facing during this difficult time and we want to hear from all behavioral health care providers what else we can do to help.” – Julia Finken, Executive Director, Behavioral Health Care Accreditation *

This Too Shall Pass

“This too shall pass” is comforting and indeed it will (or be better controlled). But, as the pandemic stretches on and businesses start to develop a “new normal” for addressing the various health and economic needs of the public at large, a pre-laid foundation of strategic plans and detailed response initiatives can provide a more effective pivot for a company.

Is your organization one of them? By scheduling time to focus on accreditation, you can address key initiatives now and stay ahead of the game in the future. Don’t delay your preparation for achieving accreditation. Develop a work schedule that includes accreditation preparation whether you are applying for the first time or maintaining your status.

Keep Your Momentum Going!

*For additional information from the accrediting bodies:

CARF International

COA “Preparing for Response to COVID-19”

The Joint Commission

Accreditation In Action – Congratulations HeartShare and HeartShare St. Vincent’s Services of New York City!

We congratulate HeartShare Human Services of New York and HeartShare St. Vincent’s Services of New York City on receiving their re-accreditation through COA, Council On Accreditation!

Since its founding in 1914, HeartShare and its Family of Services has expanded to more than 100 program sites in Brooklyn, Queens and Staten Island and operates in 60 of the 62 New York counties through energy grants. HeartShare’s responsiveness to the needs of the New York community guides its innovation. When the community desired special education classrooms, HeartShare opened a school for children with autism. When young adults aging out of foster care required a safety net, HeartShare St. Vincent’s Services created the American Dream Program to help youth achieve their college and career dreams.

“Imagine that you are coordinating two re-accreditations for large multi-service organizations at the same time. Accreditation Guru worked diligently with us to make sure our responses were clear and concise, turning this into a learning process that helped our organizations strengthen their best practices and alleviate challenges. In the end, we not only submitted our self-studies three days before the due date, but also received two expedited re-accreditations. This would have been impossible without the assistance of Accreditation Guru.” – Stanley Capela, Vice President of Quality Management

For more information on HeartShare Human Services of New York – visit their website.

For more information on HeartShare St. Vincent’s Services of New York City – visit their website here.

Accreditation In Action – Congratulations Shamah Autism Center!

We congratulate Shamah Autism Center on achieving their three-year accreditation through CARF International!

Shamah Autism Center, located in Saudi Arabia, is a special education school providing education for children 3 to 12 years with autism spectrum disorders, Asperger syndrome and associated social and communication difficulties.
“We are extremely grateful for Accreditation Guru for the consultation services provided throughout our survey preparation process. We extend special thanks and appreciation to Carol Smith for her time and effort to support Shamah Autism Center to obtain the three-year CARF accreditation. She was always accessible, and ready to answer all our questions and guide us. The online mock survey helped us figure out the areas needing improvement and thus be well-prepared for the survey. CARF surveyors were very impressed with our readiness. We strongly recommend Accreditation Guru for any organization seeking CARF accreditation.” – Sokynah Al-abkari, Quality Assurance Specialist, Shamah Autism Center.
To learn more about this organization – visit their website.