Achieving CARF (Commission on Accreditation of Rehabilitation Facilities) accreditation is a major milestone for any human services or healthcare organization. It demonstrates your commitment to high-quality care, strong organizational processes, and continuous improvement. However, many organizations, especially those preparing for accreditation for the first time, unknowingly make mistakes that jeopardize their success.
This resource outlines the most common pitfalls that could threaten your CARF accreditation and provides guidance on how to avoid them.
1. Lack of Proper Documentation
CARF places a strong emphasis on written, verifiable processes. One of the biggest mistakes organizations make is assuming that “we do it, so it’s fine.” CARF requires evidence.
Common documentation issues include:
- Missing or outdated policies and procedures
- Failure to document staff training and credentials
- Incomplete incident reports or follow-up documentation
- No written evidence of risk management, quality improvement, or safety activities
How to avoid:
Maintain a documentation schedule, conduct routine audits, and ensure all policies are current, approved, and consistently implemented.
2. Outdated or Inconsistent Policies and Procedures
CARF reviewers look for alignment between what your written policies say and what your staff actually does. Inconsistent or contradictory policies are red flags.
Common issues include:
- Policies not reflecting actual practices
- Missing required CARF policy elements (e.g., accessibility, rights of persons served)
- Policies updated in one department but not across the organization
How to avoid:
Review your policies annually and ensure all staff are trained on updates.
3. Poor Staff Training and Inadequate Competency Documentation
CARF expects organizations to demonstrate that staff are trained, qualified, and competent. Missing or incomplete training records can lead to major deficiencies.
Key training that is often missing:
- Confidentiality & HIPAA/PHI
- Emergency procedures
- Safety and risk management
- Cultural competency
- Job-specific training
- Mandatory annual refreshers
How to avoid:
Use a centralized training tracking system and standardize onboarding and annual training requirements.
4. Weak Performance Measurement and Quality Improvement (QI) Programs
CARF heavily evaluates your organization’s Quality Improvement processes. If your QI program is poorly documented, inconsistent, or nonexistent, it can jeopardize accreditation.
Common mistakes include:
- Collecting data but not analyzing it
- No clear benchmarks or goals
- Not showing year-to-year improvements
- No documented action plans based on findings
How to avoid:
Establish a structured PMQI plan with measurable indicators, routine reviews, and documented improvement actions.
5. Ineffective Risk Management
CARF requires organizations to proactively identify, assess, and mitigate risks. Organizations often fail to provide evidence of:
- Annual risk assessments
- Documented incident trends
- Emergency preparedness drills
- Financial risk analysis
- Cybersecurity protocols
How to avoid:
Conduct regular risk reviews, maintain logs, and ensure leadership oversees risk mitigation efforts.
6. Non-Compliance with Health, Safety, and Environment Standards
Safety issues are one of the fastest ways to fail a CARF survey. Reviewers expect to see:
- Clear safety protocols
- Accessible and updated emergency plans
- Equipment inspections and maintenance logs
- Fire and emergency drill documentation
- Clean, hazard-free environment
How to avoid:
Schedule monthly safety checks and maintain all documentation in an organized system.
7. Missing or Insufficient Strategic Planning
CARF standards require organizations to show strategic direction and long-term planning. Missing or outdated strategic plans can jeopardize accreditation.
Mistakes include:
- Plans older than three years
- No measurable goals
- No input from stakeholders
- No monitoring or progress reports
How to avoid:
Maintain a three-year strategic plan and ensure leadership regularly reviews progress.
8. Incomplete or Inconsistent Person-Centered Service Planning
CARF emphasizes individualized services. Many organizations fail to demonstrate:
- Person-centered goals
- Consistent progress notes
- Documented input from clients and families
- Timely updates to service or care plans
How to avoid:
Train staff in person-centered planning and use standardized formats for documentation.
9. Poor Communication and Lack of Staff Preparedness
Another major mistake is not preparing staff for what to expect during a CARF survey. Staff should understand:
- Their roles
- Your organization’s mission and values
- Relevant policies that apply to them
- Program goals
- Safety procedures
How to avoid:
Conduct mock surveys and train staff on CARF standards that relate to their functions.
10. Waiting Too Long to Prepare
One of the most damaging mistakes is beginning preparation too close to the survey date. CARF looks for consistent implementation over time, not last-minute fixes.
Signs of rushed preparation:
- Missing documentation
- Staff unaware of policies
- Disorganized files
- Incomplete QI cycles
How to avoid:
Start preparing at least 6–12 months before your survey
Final Thoughts
By understanding potential pitfalls and developing a proactive, comprehensive approach, organizations can not only achieve CARF accreditation but also establish a culture of continuous improvement and exceptional service delivery.