Overview

All legal and regulatory requirements of Federal, state, provincial, county, and city entities must be adhered to throughout the course of the CARF survey and accreditation award time period.

Accreditation Requirement(s)

To be in conformance with these accreditation standards, the organization must show evidence of the following:

• During the site survey, any reports from all legal actions, regulatory agencies, and contractual relationships are provided to the survey team for review.
  
  
• A synopsis report is provided to CARF if any of the following has occurred during the previous 3 years: litigation, allegations of wrongdoing, malpractice, and violations of the organization's Code of Ethics.
  
  
• The organization complies with all legal and regulatory requirements that may include, but not be limited to:
  
  
  • Rights of the person served
  • Confidentiality
  • Reporting requirements
  • Contractual agreements
  • Licensing
  • Corporate status
  • Employment practices
  • Mandatory employee testing
  • Privacy issues

Implementation Tips

Some Implementation Tips provided, in part, by Robert Johnson at: www.accreditationnow.com.

• From the beginning, when the organization signs the Intent to Survey (the CARF accreditation application), it agrees to abide by all legal requirements.
  
  
• During the site survey the organization should be prepared to share any reviews from outside entities, legal proceedings, and/or contracts. Have a contract file available, reports from licensing and/or regulatory bodies (such as state licensing reviews, Medicaid audits, managed care program evaluations), and/or legal reports (from investigations/allegations) ready to show the survey team.
  
  
• Be sure that all applicable licenses are posted prominently throughout the organization.
  
  
• Reports of allegations/investigations/legal proceedings/corporate compliance problems can be in synopsis format. This allows the organization to conceal the details and maintain the privacy of those involved.
  
  
• If litigation, malpractice, an unexpected occurrence involving death or serious physical or psychological injury (a sentinel event), a major catastrophe, or an investigation occurs during the tenure of the organization's CARF accreditation, then the organization must also adhere to CARF's policies and procedures (found in the accreditation standards manual) of communicating these significant events to the CARF office at the time they occur.