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Expert Guidance Through Every Accreditation Path
At Next Step Health & Human Service Consulting, we specialize in guiding behavioral health organizations through various accreditation and certification processes. Our founder Tanya Brice’s unique position as both an active CARF surveyor and an experienced behavioral health professional gives our clients an invaluable advantage in navigating these complex journeys.
Overview of CARF Requirements
- Leadership and Governance: Organizational structure, strategic planning, and ethical practice
- Financial Management: Budgeting, financial reporting, and fiscal responsibility
- Risk Management: Identifying and mitigating operational and clinical risks
- Health and Safety: Creating secure environments for clients and staff
- Human Resources: Staff qualifications, supervision, and professional development
- Quality Improvement: Systems for ongoing evaluation and enhancement
- Rights of Persons Served: Protecting client autonomy and dignity
- Program-Specific Standards: Requirements tailored to your specific service types
Our CARF Surveyor Expertise
- Understand exactly what surveyors look for during site visits
- Stay current with emerging trends and shifting interpretations of standards
- Can distinguish between “must-have” requirements and “nice-to-have” enhancements
- Anticipate common survey challenges before they arise
- Translate complex standards into practical operational changes
Success Rate with CARF Clients
- 100% approval rate for both preliminary and three-year CARF accreditation
- Every client we’ve prepared has achieved accreditation on their first attempt
- Our clients consistently receive minimal recommendations (improvement areas)
- Many clients achieve the coveted three-year accreditation on their first survey
- Organizations we guide typically receive commendations for quality practices
CARF Preparation Process
- Initial Assessment: Evaluation of current operations against CARF standards
- Gap Analysis Report: Detailed findings with prioritized recommendations
- Standards Implementation: Development of required policies, procedures, and systems
- Documentation Creation: Design of compliant forms, manuals, and records
- Performance Improvement System: Implementation of robust quality monitoring
- Outcomes Measurement: Development of tools to track and demonstrate effectiveness
- Staff Training: Comprehensive education on standards and interview preparation
- Mock Survey: Realistic practice evaluation conducted by experienced professionals
- Final Preparation: Last-minute refinements based on mock survey findings
- Survey Support: Guidance during the actual CARF survey process
The Joint Commission
The Joint Commission (formerly JCAHO) sets rigorous standards for healthcare organizations nationwide. Their behavioral health accreditation is highly respected and can enhance your organization's reputation, payer relationships, and quality outcomes.
Joint Commission accreditation for behavioral healthcare focuses on:
- Environment of Care: Physical facilities, safety systems, and emergency preparedness
- Information Management: Record-keeping, confidentiality, and continuity of care
- Leadership: Organizational direction, planning, and accountability
- Life Safety: Fire protection, building safety, and hazard management
- Medication Management: Prescribing, administration, and monitoring practices
- Performance Improvement: Data-driven quality enhancement
- Rights and Responsibilities: Client involvement and protection
- Screening and Assessment: Comprehensive evaluation of client needs
- Care, Treatment, and Services: Evidence-based interventions and individualized planning
- Staff Qualifications: Credentialing, competency, and ongoing evaluation
Joint Commission standards are particularly focused on safety, risk reduction, and evidence-based care, with continuous quality improvement embedded throughout all requirements. The standards are updated regularly to reflect emerging best practices and research findings.
Our Joint Commission preparation services include:
- Comprehensive Policy Review
- Standards Manual Interpretation
- Documentation System Design
- Quality Data Implementation
- Safety Program Enhancement
- Self-Assessment Guidance
- Survey Activity Guide Preparation
- Leadership Engagement
- Staff Education
- Mock Tracer Activities
We emphasize integrating quality improvement into everyday operations rather than treating accreditation as a separate project.
Challenge: Demonstrating ongoing compliance through "tracers"
Solution: We implement tracer methodology into your regular operations, ensuring staff can confidently participate in this interactive evaluation method
Challenge: Meeting the National Patient Safety Goals specific to behavioral health
Solution: We develop targeted improvement projects addressing each safety goal, with special focus on suicide prevention and medication safety
Challenge: Comprehensive environment of care documentation
Solution: We create streamlined systems for safety inspections, maintenance records, and hazard management
Challenge: Demonstrating leadership involvement in quality and safety
Solution: We help design governance-level reporting systems and meeting structures
Accreditation Commission for Health Care (ACHC)
The Accreditation Commission for Health Care (ACHC) offers a respected accreditation option for behavioral health organizations, with standards specifically designed for community-based providers.
ACHC behavioral health accreditation evaluates:
- Organizational Structure
- Program Requirements
- Human Resources
- Client Rights and Protection
- Health and Safety
- Quality Improvement
- Record Management
Our comprehensive ACHC support includes:
- Standards Crosswalk
- Policy Development
- Self-Assessment Tools
- Documentation Templates
- Process Integration
- Quality Measure Selection
- Staff Orientation
- Leadership Preparation
- Mock Survey
- Ongoing Implementation Support
- Application and Preparation: 3–6 months
- Document Submission: 1–2 months prior
- On-Site Survey: 2–3 days
- Report and Plan of Correction: 4–6 weeks
- Award: Valid for 3 years upon approval
Working with Next Step streamlines this process, avoids delays, and ensures compliance.
Maryland State Licensure
Building Your Foundation for Behavioral Health Services
Before pursuing national accreditation, most behavioral health organizations must first obtain state licensure. Our intimate knowledge of Maryland’s regulatory environment makes us the ideal partner for navigating this foundational process.
Requirements Overview
- Organizational Structure
- Fiscal Management
- Physical Plant
- Staff Qualifications
- Service Delivery
- Documentation
- Client Rights
- Quality Assurance
Documentation Needed
- Program Application
- Organizational Documents
- Policy and Procedure Manual
- Personnel Manual
- Client Handbook
- Quality Improvement Plan
- Emergency Procedures
- Facility Documentation
- Financial Information
- Program-Specific Materials
Our Streamlined Process
- Initial Consultation
- License Type Determination
- Gap Assessment
- Application Development
- Documentation Creation
- Physical Plant Guidance
- Pre-Survey Inspection
- Survey Preparation
- Survey Support
- Plan of Correction
DDA Certification
Serving the Developmental Disabilities Community with Excellence
The Developmental Disabilities Administration (DDA) certification represents Maryland’s quality standard for providers serving individuals with developmental disabilities.
Requirements
- Person-Centered Planning
- Rights and Protections
- Service Planning and Delivery
- Health and Safety
- Staff Qualifications
- Quality Assurance
- Community Integration
- Self-Determination
Certification Process
- Provider Application
- Documentation Review
- Staff Qualification Verification
- On-Site Inspection
- Interview Process
- Plan of Correction
- Certification Decision
- Ongoing Monitoring
How We Support DDA Providers
- Standards Interpretation
- Policy Development
- Person-Centered Planning Systems
- Rights Protection Frameworks
- Staff Training Programs
- Quality Monitoring Tools
- Documentation Templates
- Mock Surveys
- Plan Development
- Ongoing Technical Assistance
Ready to Take the Next Step?
Contact us today to discuss which accreditation path best aligns with your organization’s mission, services, and goals. Our expert team will guide you through every phase of the journey.