Primary Source Verification of Credentials

The November 2014 newsletter of Behavioral Health Resources, LLC provides information about the CARF standards for Human Resources.

CARF Standard 1.I.2.a(b)  –  Human Resources.   This Primary-Sourcestandard in the Human Resources section of the 2014 BH/CYS/OTP Standards Manuals states that organization should implement written procedures to obtain primary source verification for all credentials of personnel including  licensure.

What is Primary Source Verification?  Verification of credentials should be obtained from the original source to determine the accuracy of the qualifications of an individual health care practitioner. Examples of primary source verification include, but are not limited to, direct correspondence, telephone verification and internet verifications.  (The original source is the academic institution or professional licensing authority.)

Licensure Search in NebraskaExamples of Appropriate Verification.  Examples include an original letter from the proper authority, an official copy of the college transcript mailed directly from the academic institution to the employer, and a copy of the webpage listing from the licensing authority.  (For an example of how to obtain professional licensure search in Nebraska, click here.)

The CARF Examples statement for this standard indicates that primary source verification is not needed for high school diplomas.   Because primary source verification of education and degrees is obtained when a professional obtains state or provincial licensure, this is not needed by the employer if primary source verification is obtained for the professional licensure (unless required by the organization’s policies).

For documents that are obtained from the original authority via Internet webpages, it is suggested that additional validation be provided by the organization.  This could include the signature and date on the file document of the person who obtained the primary source verification.  (CARF surveyors periodically suggest this additional step.)

Types of Verification to Avoid.   Copies of licenses, credentials, college transcript, etc. provided by personnel do NOT meet the primary source verification requirement.

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CARF 2014 Standards Manual Changes

The March-April 2014 newsletter of Behavioral Health Resources, LLC focuses on changes to the CARF 2014 BH/CYS/OTP Standards Manuals.

The 2014 Standards Manuals and all changes will be effective on July 1, 2014. Will your organization be ready to implement the changes?   Our March-April 2014 e-newsletter provides information about standards that will pertain to all CARF-accredited organizations. These changes were discussed by CARF managers at a CARF 101 training held in Tucson in March 2014.

MEDICATION USE – Standard 2.EMedication Use System

Training Requirements – 2.E.2. In previous editions of the BH/CYS Standards Manuals, standard 2.E.2 only pertained to organizations that prescribe, dispense, control, or administer medications in accredited programs and they were required to consider applying the standard. However, new to the 2014 Standards Manuals is a change in wording so that all organizations must apply 2.E.2 whether or not medications are used in the programs.  If the organization does not prescribe, dispense, control, or administer medications, then this requirement for documented ongoing training and education of 16 topics only pertains toRX_Medication personnel. (If the organization uses medications in the programs, then the training requirement also pertains to persons served and family members.)

As stated in the Intent Statement (BH, p. 128; CYS, p. 134): “If a program seeking accreditation does not provide medication control, prescribing, dispensing, or administering, it would not be required to provide ongoing training and education regarding medications to the persons served or any family member. Training and education should be provided to personnel providing direct service to the persons served in all programs seeking accreditation.”

This standard indicates that the training and education of personnel only needs to be documented. It is not required to be competency-based. Therefore, an easy way for an organization to comply with this standard is to have a medical professional (e.g., physician, nurse practitioner, nurse, pharmacist) provide a 1-2 hour workshop on-site with an agenda that includes all 16 required topics and an attendance sheet that is dated and includes signatures of all participants.  NOTE: If some, but not all, direct-service personnel attend the training, this would be partial conformance and a recommendation would be given during an on-site survey.

© 2014 Behavioral Health Resources, LLC. All rights reserved.

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CARF Health & Safety Standards – Hazardous Materials

The January-February 2014 newsletter of Behavioral Health Resources, LLC focuses on CARF standards for hazardous materials.  In the Health and Safety section of the 2013 BH/CYS/OTP Standard Manuals, standard 1.H.14 states that there should be written procedures concerning hazardous materials that provide for safe handling, storage, and disposal.

Many employees may not realize that this includes fluorescent light bulbs, copier toner, and computer monitors.  Because all organization have these items in their offices, the requirement for written procedures likely pertains to every CARF-accredited organization. Information about these hazardous materials is provided below.

Fluorescent Light Bulbs.  According to the Environmental Protection Agency (EPA): fluorescent light bulbs“Under federal regulations, the vast majority of mercury-containing lamps are considered a hazardous waste. If you do not test your mercury-containing lamps and prove them non-hazardous, you must assume they are hazardous waste and handle them accordingly . . . . Management and disposal by businesses of fluorescent light bulbs and other mercury-containing bulbs are managed under both federal and state regulations . . . . Regulations may vary from state to state, and some states have regulations that are more stringent than those of the federal government.  As a result, you should check with your state and local governments to learn how their regulations apply to your business.”

What’s an easy way to know if a fluorescent light bulb contains mercury or similar hazardous material?  The Lamp Material Data Sheet (LMDS) is a good source of information.  This is available when the light bulb is purchased or can likely be found on-line.  As an example, click here to obtain the LMDS for a Philips linear fluorescent light bulb. This light bulb is sold at stores such as Home Depot and is advertised for residential and industrial use.  For information about safe handling, recycling, and disposal of fluorescent light bulbs, read more . . .

Copier Toner.  How is copier toner a hazardous material?  As described in an on-line article by Kyle McBride:  “In modern copy machines, the toner cartridges and toner 16802-sharp-ar-202ft-copier-toner-1delivery systems are designed and intended to function in such a way that there is no human contact with the toner.  The reality is, however, that the copy machine operators do come into contact with toner.  Cartridges malfunction, components in the machine break exposing toner to the environment, and there can be unfused toner on paper pulled from the machine when clearing a paper jam.  These are ordinary ways that a copy machine operator can be exposed to toner.”  Click here to learn more about safe cleanup and disposal. Information is also available in the Material Safety Data Sheet (MSDS) which is available from the manufacturer.

Computer Monitors. A s reported by R-Tools Technology, Inc:  “Computer monitors, as computer monitorwell as other electronic equipment, is considered hazardous waste.  Computer monitors and other eWaste can be harmful if it is left in a landfill, as it contains a number of chemicals and compounds that can seep into the groundwater and soil.  These harmful substances can be reintroduced into the environment or even into drinking water supplies.”  Safe disposal of computer monitors can be done in several ways: donate it; participate in an e-Waste collection drive; send it to the manufacturer; or bring it to a Big Box Store.  Read more . . .

© 2014 Behavioral Health Resources, LLC. All rights reserved.

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CARF Standards for Technology Plans

The November-December 2013 newsletter of Behavioral Health Resources, LLC focuses on CARF standards for Technology Plans.  Section 1.J of the CARF 2013 BH/CYS/OTP Standards Manuals states that accredited organizations should implement a technology and systems plan that includes eight areas. These are described below:Technology Plan

  • Hardware. The mechanical, magnetic, electronic, and electrical components making up a computer system.
  • Software.  Written programs or procedures or rules and associated documentation pertaining to the operation of a computer system and that are stored in read/write memory.
  • Security.  Information security as applied to technology such as Internet, electronic transmissions (e.g., fax and e-mail), computers, networks, and cell phones. The field covers all the processes and mechanisms by which computer-based equipment, information and services are protected from unintended or unauthorized access, change or destruction. Computer security also includes protection from unplanned events and natural disasters.
  • Confidentiality.  In this context of technology, confidentiality is a set of rules that limits access to information by authorized personnel.  Confidentiality prevents sensitive information from reaching unauthorized personnel and ensuring access by authorized personnel.  Common methods of ensuring confidentiality include:  date encryption, User IDs, Passwords, two-factor authentication, and biometric verification.  In addition, users can take precautions to minimize the number of places where the information appears and the number of times it is actually transmitted to complete a required transaction.
  • Backup Policies.  Backup policies should include:  1) the method of backup to be used; 2) types of data to be backed up; 3) when data needs to be backed up; 4) administrators; 5) how to protect the backups (i.e., security in case of fire or other destruction).
  • Assistive Technology.  Any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase or improve functional capabilities of individuals.
  • Disaster Recovery Preparedness.  The process, policies, and procedures that are related to preparing for recovery or continuation of technology infrastructure which are vital to an organization after a natural or human-induced disaster.  Disaster recovery focuses on the IT or technology systems that support business functions.
  • Virus Protection.  Antivirus or anti-virus software is software used to prevent, detect and remove malware (of all descriptions), such as: computer viruses, malicious BHOs, hijackers, ransomware, keyloggers, backdoors, rootkits, trojan horses, worms, malicious LSPs, dialers, fraudtools, adware and spyware.

CARF Definition of a Plan.  As described in the Glossary of the 2013 BH/CYS/OTP Standards Manuals, a plan is:  “Written direction that is action oriented and related to a specific project or defined goal, either present and/or future oriented.  A plan may include the steps to be taken to achieve stated goals, a time line, priorities, the resources needed and/or available for achieving the plan, and the positions or persons responsible for implementing the identified steps.”  Many organization receive recommendations during their CARF surveys because their plans are not working documents (i.e., are written as policies).  The CARF definition of a policy is:  “Written course of action or guidelines adopted by leadership and reflected in actual practice.”

Office-TechnologyCurrent and Projected Technology Needs.   An effective Technology Plan will include specific description of the organization’s current technology.  The Plan should also be a working document (i.e., Action Plan) that includes unmet and projected technology needs and a time line with possible vendors, estimated or actual cost, person responsible, target date, and completion date for each of the eight areas.

For more information about how to develop an effective Technology Plan (to include the Action Plan), contact a CARF Consultant, Brenda Rohren, at (402) 486-1101 or

© 2013 Behavioral Health Resources, LLC. All rights reserved.

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Behavioral Health Resources, LLC Verified as Veteran-Owned Small Business

VOSB logoBehavioral Health Resources, LLC is proud to announce that in October 2013, we obtained status as a verified Veteran-Owned Small Business (VOSB).  This means that our company is eligible to participate in Veterans First Contracting Program opportunities with the Veteran’s Administration (VA).  The VA is one of the largest Federal Government procurement organizations that provides over $3 billion in resources to Veteran-owned small businesses.  Eligibility is determined by the company’s ability to meet the small business requirements set by the Small Business Administration (SBA) size standards.  Verification was awarded to Behavioral Health Resources, LLC following investigation and confirmation of the business owner’s veteran status and capabilities in the field.

Assistance with the VOSB application was provided by Jason Bousquet, Procurement Technicalnbdc Assistance Consultant with the Nebraska Business Development Center (NBDC).  Jason can be contacted at (402) 472-1177 or

Behavioral Health Resources, LLC is eligible for government contracting under following NAICS codes:

  • 541611  –   Management Consulting
  • 621330  –  Offices of Mental Health Practitioners (except physicians)
  • 621420  –  Outpatient Mental Health and Substance Abuse Centers

Our services include a Dual Diagnosis Outpatient treatment program with an emphasis on trauma-informed care and EMDR therapy.  Specific services are substance use, mental health, and trauma evaluations as well as individual, family, and group therapy.  We also provide management consulting for CARF accreditation.

BHR_logo_newTaglineFinal (8-12-13) (2)To learn more about our services or to schedule a free consultation, contact Brenda Rohren at (402) 486-1101 or  For more information, visit our website.

© 2013 Behavioral Health Resources, LLC. All rights reserved.

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CARF Standards for Abuse, Neglect, and Trauma Assessment

The September-October 2013 newsletter of Behavioral Health Resources, LLC focuses on CARF standards for documenting history of trauma during the assessment process.

As indicated in Section 2.B of the 2013 BH/CYS*/OTP Standards Manuals, the assessment process should gather and record information about the person’s history of trauma that is experienced and witnessed, and include abuse, neglect, violence, and sexual assault.  (*Standards in the CYS manual do not include sexual assault.)

Sad Girl - head and shouldersA trauma history is more than basic questions such as, “Have you ever been emotionally, physically, or sexually abused?”  What constitutes an adequate basic trauma assessment?   This would include adverse life experiences as well as traumatic events.  Examples include:  transportation accidents (e.g., car, airplane); natural disasters (e.g., tornado, earthquake); crimes (e.g., robbery); exposure to dangerous chemicals; life-threatening illness; death of a loved one; and many more.

Click here to obtain a good example of a brief Trauma History Questionnaire that is available from the Georgetown University Medical Center (provided as a Word document).  Their website also includes Tool Kits for the trauma assessment published in Spanish and other useful assessment tools.

Trauma-Informed Services

The following information was obtained from SAMHSA.

What is Trauma-Informed Care?   Most individuals seeking public behavioral health services and many other public services, such as homeless and domestic violence services, have histories of physical and sexual abuse and other types of trauma-inducing experiences.  These experiences often lead to mental health and co-occurring disorders such as chronic health conditions, substance abuse, eating disorders, and HIV/AIDS, as well as contact with the criminal justice system.

When a human service program takes the step to become trauma-informed, every part of its organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services.  Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.

What are Trauma-Specific Interventions?   Trauma-specific interventions are designed specifically to address the consequences of trauma in the individual and to facilitate healing.  Treatment programs generally recognize the following:

  • The survivor’s need to be respected, informed, connected, and hopeful regarding their own recovery
  • The interrelation between trauma and symptoms of trauma (e.g., substance abuse, eating disorders, depression, and anxiety)
  • The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers


Consultants at Behavioral Health Resources, LLC do not represent CARF.

© 2013 Behavioral Health Resources, LLC. All rights reserved.

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CARF Standards for Written Ethical Codes of Conduct

The July-August 2013 newsletter of Behavioral Health Resources, LLC focuses on CARF standards for corporate compliance that includes written ethical codes of Scale-w-Ethics-Law-Book1conduct.

According to the Ethics Resource Center (ERC), “A code of conduct is intended to be a central guide and reference for users in support of day-to-day decision making.  It is meant to clarify an organization’s mission, values and principles, linking them with standards of professional conduct.  As a reference, it can be used to locate relevant documents, services and other resources related to ethics within the organization.”

Section 1.A (Leadership) of the CARF 2013 BH/CYS/OTP Standards Manuals includes written ethical codes of conduct in a minimum of 13 identified areas.   During accreditation surveys, recommendations are frequently received in 4 of the service delivery areas:

1.A.6.a(4)(b)   Exchange of gifts, money, and gratuities.  Conformance to this standard could be addressed by stating that no personnel or other persons associated with your organization will accept gifts of money or material value, favors, remuneration, or other consideration from any client, individual, or organization that does business with your organization.  It is important to state if gifts from clients of low monetary value are acceptable (i.e., whether purchased or handmade).  If so, the specific dollar amount (e.g., $20) should be indicated as well as who has the authority in the organization to approve the gift.

The ethical code could also indicate the guidelines for approving and accepting the gift (e.g., that decisions will be based on the therapeutic benefit to the client).  If a gift is received from a client or other stakeholder (e.g., client’s family, external vendor, or referral source), it could be stated that the gift is turned in to the supervisor and considered to be a donation to the program or organization.  Another consideration pertains to allowing pictures to be taken or exchanged.

1.A.6.a(4)(c)   Personal fund raising.  According to the Examples section in the CARF 2013 Standards Manuals, (e.g., BH, page 35), personal fund raising includes:  “personnel soliciting funds on behalf of a personal cause, Personal Fundraising - magazinesselling cookies for a daughter in girl scouts, selling candy or wrapping paper for a child’s school, having persons served sell items on behalf of the organization, and allowing persons served to raise funds by appeals to personnel and other persons served.”

Your organization needs to decide if and under what circumstances personal fund raising is allowed.   What materials are approved or authorized on the organization’s bulletin boards or for distribution (e.g., placed in employee lockers or individual mailboxes)?   Is it allowed to circulate various charity promotional items (such as magazine sales for various school projects) during work time, while on break, or on the organization’s premises?   Are employees allowed to solicit for personal fund raising during their bona fide break time?  If so, it could be stated that this is allowed provided that it is not done in the presence of clients and not in areas frequented by clients.  Who has the authority to approve personal fund raising or to make exceptions to your policy?

1.A.6.a(4)(d)   Personal property.  A statement that would adequately meet the standard is:  “All personnel shall respect and safeguard the personal property of clients, visitors, and other personnel as well as the property of [name of organization].  Employees will not use or allow the use of [name of organization] property or equipment for other than activities approved by the organization.  Theft and destruction of property may be addressed through treatment planning (clients), disciplinary action (personnel), and/or by contacting law enforcement, as appropriate.  The organization could also state that it is not responsible for personal property that is not safeguarded or is left unattended.

1.A.6.a(4)(f)   Witnessing of documents.  If not allowed in your organization, this statement would adequately meet the standard:  “Personnel shall not act as a witness to documents such as Power of Attorney, guardianship, advance directives, and/or agency contracts without the expressed written approval of the ______ [indicate the job position at your organization].  Personnel are authorized to countersign documents such as intake forms, authorizations (i.e., release of information form), treatment plans, etc. as directly related to their job duties.”

Notary Public signature and sealIf witnessing documents is acceptable by personnel who are certified as Notary Publics and this is a component of their job duties, a possible statement in the ethical code could be:  “Employees who are certified as Notary Publics may witness documents such as Power of Attorney, guardianship, advance directives, and/or agency contracts for clients, personnel, and other stakeholders in accordance with applicable state laws.  The person who witnesses a document should be neutral and have no financial or other interest involved.”  If witnessing of these types of documents is allowed by personnel certified as Notary Publics or other designation, your organization could benefit from developing a specific policy and procedure regarding this.

© 2013 Behavioral Health Resources, LLC. All rights reserved.

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New CARF Standard for Social Media

The May-June 2013 newsletter of Behavioral Health Resources, LLC focuses on a new CARF standard for social media.   Standard 1.G.3.b in the 2013 BH/CYS/OTP Standards Manuals isa requirement for accredited programs to implement risk management  procedures regarding communications that address social media.

An excellent resource is a book published in 2012 by Nancy Flynn, The Social Media Handbook“The Social Media Handbook: Policies and Best Practices to Effectively Management Your Organization’s Social Media Presence, Posts, and Personal Risks.”  The book provides information such as: legal compliance; how social networking creates legal evidence; how to manage records and e-discovery compliantly; privacy, security, and social media; risks associated with blogs and mobile devices; conducting a social media policy audit; writing effective social media policies; responding to and recovering from a social networking nightmare; sample policies for social media, blogs, and related AUPs.  Chapter 15 is a glossary of social media, legal, regulatory, and technology terms.

Click here to obtain a social media policy for a CARF-accredited organization that is available in the public domain.

Even if it enrages your boss, social net speech is protected.  “As Facebook and Twitter become as central to workplace conversation as the company cafeteria, federal regulators are ordering employers to scale back policies that limit what workers can say online.”  Click here to read more about the topic from the January 21, 2013 article of the New York Times.

Is it ethically and legally appropriate for a behavioral health provider to engage in social media networking through sites like Facebook and LinkedIn?

The following is from an article by Healthcare Providers Service Organization (HPSO), a professional liability insurance company affiliated with the American Counseling Association (ACA).

HPSOThe answer is that it depends on how you’re using the sites and what you’re doing to protect client confidentiality and avoid boundary violations.  Those are currently the biggest areas of concern in using social media. The ACA Code of Ethics (2005) is in the process of being revised, as are many state licensure laws, so all counselors are advised to be aware of upcoming changes in ethics and law regarding social media and other uses of technology.

If you or your employees intentionally or inadvertently disclose confidential client information on social networking sites, that could pose an ethics violation and lead to legal problems under HIPAA, HITECH and state law.  The HITECH regulations supplement HIPAA and require “covered entities” (including most counselors in private practice) and “business associates” of covered entities to take certain action in the event of a breach of protected health information.  If you are supervising counselors or students, you should also take care to ensure they are following your practice’s HIPAA policies and procedures.  If a breach occurred, the HITECH regulations would require you to perform a risk assessment and take action, such as formal notice to clients adversely affected by the breach and notice to the U.S. Department of Health and Human Services.

One lasting problem with social networking sites is that information posted cannot be removed.  Additionally, if information is reposted by a person to another page, you may lose control of who sees potentially confidential information.  A counselor who engages in social media must learn to use privacy settings appropriately.

Boundary violations regarding use of social media have led to complaints against mental health professionals in very recent years.  Clients may feel rejected if they know a counselor has agreed to be “friends” with other clients but not with them.  Counselors should consider addressing their use (or non-use) of social media through their informed consent process and documents.  It is very important to separate one’s personal use of social media from one’s professional use.

Despite the many caveats applicable to use of social media, appropriate professional use may prove beneficial to clients and counselors under controlled circumstances in order to provide resources to clients or the public.  It may provide connections to other professionals in the community that may well serve the public.  However, you must fully consider the myriad of privacy and boundary issues before “friending,” “tweeting,” or “liking.”

© 2013 Behavioral Health Resources, LLC. All rights reserved.

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Evidenced-Based Practices & Assessment of Competency

The April 2013 newsletter of Behavioral Health Resources, LLC focuses on CARF standards related to assessment of competency and evidence-based practices.

What is competency?   Competency refers to a professional’s level of skill in delivering a particular treatment.  Adherence is the extent to which techniques match what is described in the training curriculum.  Consistent adherence to the identified approach results in better client outcomes.  Competence requires a good understanding of the theory, treatment outcome literature, and demonstration of techniques.  


Evidence-based practice implies that: 1) there is a definable outcome; and      2) it is measurable.   When assessing competence, it is beneficial to have an objective measurement of conformance to the evidence-based practice.  ______________________________________________________________

How do we know if a professional is competent?  Ideally, competence assessment should be based on multiple sources and methods, to include a mixture of subjective and objective information.  Clinical supervision can be a helpful approach to evaluate knowledge.  However, objective measures are needed to evaluate performance based on a clearly defined criteria of competence.  This can be done by the use of competency rating scales developed for the therapy approach for which the provider is being evaluated.     

Demonstration of Competency.  Phoenix House is a substance abuse treatment center that uses more than 35 evidence-based practices in their treatment programs.  According to Britta Muehlbach, Vice President and Director of New Business Development at the Phoenix House Foundation, “The clinical supervisors observe evidence-based sessions twice a year to monitor implementation fidelity.”  This is perhaps the best way to evaluate performance and adherence to therapy techniques and approaches.   

As described by Manring, Beitman, and Dewan in their article, “Evaluating Competence in Psychotherapy,” the following is a list of skills for evaluating competency in Cognitive Behavioral Therapy (CBT).   Can the clinician:  1) state the cognitive model; 2) socialize the client into the cognitive model; 3) use structured cognitive model activities (mood check, bridging to prior session, agenda setting, homework review, capsule summaries, and patient feedback; 4) identify and elicit automatic thoughts; 5) state and employ knowledge of cognitive triad of depression; 6) use dysfunctional thought records as a tool in therapy; 7) identify common cognitive errors in thinking; 8) use activity scheduling as a tool in therapy; 9) use behavioral techniques as a tool in therapy; and 10) plan booster sessions, follow-up, and self-help sessions appropriately with patients when terminating active therapy.

For Eye Movement Desensitization and Reprocessing (EMDR) therapy, there is an 8-phase protocol that includes:  1) history and treatment planning; 2) preparation; 3) assessment; 4) desensitization; 5) installation; 6) body scan; 7) closure; and 8) re-evaluation.  Assessment of competency would include evaluation of how closely the clinician follows the established protocol. 

Importance of Individualized Treatment.  In addition to technique, competence also includes a good working alliance with the client.  As stated by  the American Psychological Association, “Evidence-based practice in psychology . . . is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”    Rigid adherence to techniques and protocols that do not consider client factors can be negatively related to therapist competence.  Therefore, client satisfaction surveys can also be a useful tool.

Additional Assessments for Competency.  Other methods used to evaluate competency include client record audits, performance evaluations, oral exams, written exams (multiple choice, essay, short answer, and case review), and global rating scales.     

Competency-Based Training.  Does your organization have an individualized training program for each direct-service provider?  For example, if a clinician uses EMDR therapy, is it expected that the therapist will obtain continuing education (i.e.,attend EMDR SAMHSA Evidence-Based Toolkitworkshops for CEUs) during the evaluation period to maintain competency?  Does the therapist participate in individual or group consultation with an approved EMDR consultant?  For information about how organizations can develop competency-based training from the 2007 issue of CARF Connect, click here.   

Integrated Treatment for Co-Occurring Disorders.  To obtain a copy of SAMHSA’s “Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices (EBT) Toolkit, click here.

© 2013 Behavioral Health Resources, LLC. All rights reserved.

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Identifying & Training an Internal CARF Consultant

Interviews with CARF Surveyors  –  Part 3 of a 3-part series

The March 2013 newsletter of Behavioral Health Resources, LLC features interviews with three CARF surveyors who are also CARF internal consultants in their organizations:  Pat Coleman, President & CEO of Behavioral Health Response (Admin surveyor for 5 years); Rob Snyder, Director of Quality Assurance at Gilead Community Services (Admin surveyor for 4½ years); Gloria Woodruff, Program Director at Whiteside Manor (Admin and Program surveyor for 9 years).

Most organizations do not have a CARF surveyor on staff.  Because preparing for a CARF survey can be a very time-consuming and complex process, organizations can benefit from selecting an employee to be an internal CARF consultant.

Identifying an Employee to be an Internal CARF Consultant.  Regarding the basic knowledge and skill level needed for the ideal candidate, Coleman states, “The ideal candidate usually is someone on the executive team with either a program or administrative background or both, or someone who works directly in the program areas.  They must be someone who is organized and very good with time management.  Also, they must hold the consumer in high regard.”  This is especially important as related to the CARF emphasis on person-centered care.

consultingcycleAccording to Snyder, “There are probably many viewpoints on this, but in mine, they need to be someone who has read through and thoroughly understands all the current CARF standards that apply to their organization.  And for anything they’re not sure on, they need to be able to get the training they need or call their CARF Resource Specialist for clarification.  They need to be someone who truly “GETS” why these standards are important and valuable to helping an organization improve services and that it’s NOT really about just getting accredited. They also need to be someone who is organized, objective, and good at attending to detail and examining systems and processes.”  Woodruff concurs.  “A concrete knowledge and understanding of the CARF standards and how they are connected to each other” is important.

What training and assistance should this person receive?  “This also probably depends on the person,” says Snyder, “but certainly at a minimum they should be attending the CARF 101’s or other trainings that CARF offers to increase their knowledge of the standards and how they can best be met.”

How could an external consultant be helpful to achieve this goal?   “Perhaps as part of their consulting process, they might be able to identify which staff appear to exhibit the qualities I indicated above and pursue that with them,” said Snyder.  The ideal situation would be to initially contract with an external CARF consultant to provide basic training to the internal consultant as well as provide periodic guidance.   (Hiring an external consultant on a Retainer Contract would be a useful investment for this purpose.)

Questions to Consider:  question

  1. Will the employee attend CARF trainings?
  2. Is a specific job description needed?  At minimum, the employee’s current job description would need to be revised to include these additional responsibilities.
  3. Does the organization have a “no retaliation” policy?  This could be included in the organization’s code of ethics document and/or written as a separate policy.  For external consultants, there is generally a clause in the contract indicating that the Consultant shall not be liable for any accreditation outcomes.  It is suggested that the organization have a similar policy and practice to protect the internal consultant so that accreditation outcomes are not reflected on the performance evaluation.
  4. Should the employee sign a nondisclosure statement?
  5. What percentage of the employee’s time will be designated for CARF-related activities?  (Refer to our  November 2013 Blog for reference.)
  6. What authority and responsibility will the employee have?   This includes:  requesting documents from staff; obtaining client caseload lists for each provider; overseeing and/or implementing changes to policies and procedures as well as other documents; training of staff regarding CARF standards and related issues.
  7. To whom will the internal CARF consultant report?   Will this person be someone other than the employee’s direct supervisor?
  8. Will the employee consistently attend management team meetings (if not already doing so)?
  9. Will the employee be designated as the CARF Accreditation Liaison on the Intent to Survey?  (If so, the employee will also be listed on CARF Survey Report as the Organizational Leadership.)
  10. What communication will the employee have with the CARF Admin Surveyor during pre-survey contact as well as the on-site survey?
  11. What role will the employee have during the on-site survey?

Click here to read an article that provides more information about advantages of using an internal consultant as well as challenges faced by this employee.

Commitment from Management and Other Stakeholders.  Snyder believes that commitment from the management team and other stakeholders is needed.  “I am the only CARF Surveyor in our organization, but with each of our organization’s surveys I have had the benefit of having another Senior Director at my organization assist me with the coordination and preparations to help our organization maintain and improve our CARF conformance and survey readiness.  I think one of the biggest challenges is how to get your organization’s stakeholders interested and invested in the process.  If you only have either an internal or external consultant or even just the organizational leadership involved, you’re not likely to be as successful as when you have everyone involved.”

Innovative ways to prepare for CARF accreditation.  Snyder offers a creative perspective on accreditation readiness.  “Finding innovative and creative ways to involve everyone in not only following and improving organizational policies, procedures, and Countdown_(Game_Show)_studiopractices that conform to the CARF standards, but also in preparing for the survey itself can be critical.  For example, I’ve organized things like agency “game shows” with prizes the year prior to our agency’s CARF surveys to help everyone refresh and improve their knowledge of CARF related practices, procedures, and policies in a fun and exciting way.  There are other factors as well, but I think some of the key tasks include being organized and planful in preparing for the survey (including preparing binders or electronic documentation in advance that you know surveyors will want to see), collaborating with all of your stakeholders and getting as much ‘buy-in’ into the importance of the process as possible, and then also systematically going through each and every standard and asking hard questions about not only whether the organization is conforming to it, but figuring out how they can demonstrate that conformance to an outside person (like a surveyor).”thank-you

Thank You!  We want to express our appreciation to Pat Coleman, Rob Snyder, and Gloria Woodruff for contributing to the January – March 2013 newsletters.


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