Overview

The organization should seek outside expertise to assist in assessing the overall safety of its locations to ensure that its services are conducted in an environment that is safe for clients, staff members, and visitors. The Health and Safety Officer (HSO) or designated safety representative is responsible for the oversight that will ensure an external safety inspection at all locations is completed annually.

Accreditation Requirement(s)

To meet the intent of these CARF standards, the organization should comply with these standards:

• An annual external inspection is conducted at all sites owned, leased, operated, or rented by the organization.
• The inspection is conducted by competent, external authorities.
• A report identifies all areas that were inspected, makes recommendations for improvement, and includes actions taken in response to the inspection.
• If the location is a congregate residential program, then one inspection must be by a fire authority at least every 3 years.

Implementation Tips

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

• One inspection every year at each site location should be conducted by competent entities, such as the fire department and the organization's insurance company, to provide a broad perspective of safety issues. Such authorities might include a licensed safety engineer, a representative of a local health department, a plant engineer or safety specialist, a safety consultant, or if part of a local city or county, a safety representative from the appropriate city/county department. Whoever conducts the inspection should be aware that a thorough inspection of the location is needed, as well as a written report. If the organization is unsure of who qualifies as a competent, external authority, it should contact the CARF office for clarification.
  
  
• The HSO may be the person who will schedule all external safety inspections in cooperation with the designated site representatives on the Health and Safety Committee, and could serve as the contact and liaison with inspection personnel and organizations.
  
  
• Members of the Health and Safety Committee who are designated representatives for each site might be responsible for facilitating the external inspections, obtaining a copy of the inspection report, and forwarding a copy of the report to the HSO for the quarterly Health and Safety Committee meetings. A log could be maintained of all inspections in order to better track them, such as:

• The designated site representatives could work in coordination with the HSO to ensure that all improvement opportunities that are a result of the safety inspection reports are addressed and corrections of deficiencies are completed.
  
  
• All inspection reports and correction activities could be reviewed by the designated Health and Safety Committee and noted in meeting documentation. The HSO will report the results of the inspections, follow-up activities, and committee recommendations to management to ensure the organization is utilizing the information to increase the level of safety throughout its operations.
  
  
• Some organizations have found that their insurance carriers are more than willing to conduct these inspections and provide a report since they view it as a preventive action. Some insurance carriers are now even giving discounts on buildings and grounds premiums if the organization conducts external inspections and is CARF accredited. This is a similar concept to getting a good driver discount on one's auto insurance premium.
  
  
• Congregate residential programs are defined as inpatient and residential treatment programs, residential therapeutic community settings, group homes, transitional community housing facilities, and detoxification programs (inpatient or residential).