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  • Thank you for your commitment to obtaining CARF certification of your organization’s ASAM Levels of Care. This document is designed to help your organization’s residential treatment program prepare for the survey. It will help you understand the survey process and how to best demonstrate to the surveyor your organization’s capacity to deliver its Levels of Care consistent with the ASAM Criteria®. This document is not, however, designed to help your organization interpret or meet the rating elements. Please contact ASAM to obtain the rating elements and for resources to help your organization satisfy the elements.

    Assessing ASAM Levels of Care

    The certification rating elements are organized by setting, staff, support system, assessment and treatment plan, therapies, and documentation. This structure provides for ease of understanding and alignment with the six service characteristics categories described in the ASAM Criteria.

    Currently, certification is available for residential treatment programs that serve adults in Levels of Care 3.7, 3.5, and 3.1. Each level is a distinct Level of Care. Your organization may have a patient that is initially admitted to Level 3.7, steps down to Level 3.5, and eventually steps down to Level 3.1 – all within your organization’s treatment program – and the person may reside in the same bed at all times.

    Since each Level of Care is separate and distinct, and will be individually assessed for certification, it is important to think about what each particular Level of Care is, how it is organized and delivered, and how it is described in your organization’s documentation. Your organization must be able to demonstrate to the surveyor during the survey that your organization, in fact, satisfies the specific rating elements for each discrete Level of Care included in the application for certification. Some elements focus on how patients are assessed, others on how they are placed into the Level of Care, and yet others on how they are transitioned from one Level of Care to another. Therefore, it is important to determine how your organization will demonstrate the service characteristics for each Level of Care to be surveyed and how it will demonstrate that a particular person receives services in one Level of Care versus another.

    Scoring

    CARF will determine the certification decision for each Level of Care by considering the findings of the survey within the context of the proprietary scoring methodology. The scoring methodology considers two factors. The first factor is demonstration of the defining elements. In the ASAM certification manual, you will notice that certain elements are highlighted. Those elements are the defining elements. The defining elements for each Level of Care address those areas deemed crucial by ASAM to the operation of all treatment programs that provide services at that Level of Care. Your organization must satisfy ALL of the defining elements for a particular Level of Care in order to be issued certification for that Level of Care. Accordingly, if even one defining element is not satisfied, your organization will not receive certification for that Level of Care. Because of the significance of the defining elements, it is critical during preparation for the survey that you very carefully consider how your organization will demonstrate satisfaction with each and every defining element. CARF recommends that you compare them to your organization’s service delivery system and make any necessary changes prior to the survey to make sure that you can provide clear and unambiguous evidence to the surveyor that each and every defining element is met.

    To emphasize the importance of the defining elements, consider Level of Care 3.5. Level 3.5 has 313 discrete rating elements. If the organization meets 312 of those elements and misses only one, but that one is a defining element, the organization will not be issued certification for Level of Care 3.5. So please make absolutely sure that you that you will be able to provide the surveyor with clear, specific evidence that demonstrates satisfaction of each and every defining element for each Level of Care included in the survey.

    The second scoring factor is demonstration of the non-defining elements. While your organization need not meet all of the non-defining elements, it must substantially satisfy these elements. So even though your organization must meet a significant proportion of the non-defining elements, it can miss some and still achieve certification.

    Each element is intended to be as clear, direct, black and white and plain language as possible, so that anyone would come to the same conclusion as to its demonstrated satisfaction. If there is language or terminology that is unfamiliar to you or you have questions about the elements or how to meet them, please contact ASAM directly.

    Prepare for Success

    How should your organization prepare for the survey? The first step is to obtain from ASAM, review, and take time to clearly understand the rating elements for each Level of Care to be surveyed. Since certification is based on demonstrated satisfaction of the elements, your organization must understand the specific requirements and expectations set forth in the elements against which its treatment program will be assessed during the survey.

    ASAM offers training modules for the Levels of Care. CARF recommends that you participate in each module that corresponds with each Level of Care to be surveyed so that you can gain a better understanding of the requirements for each Level of Care. The modules help provide context and explain ASAM's underlying rationale for each of these Levels of Care described in the ASAM Criteria. While some jurisdictions and regulatory bodies have developed their own versions of the Levels of Care, in some cases, those versions do not fully align with the ASAM Criteria and, therefore, may not align with the rating elements. CARF certification is the only program authorized by ASAM to independently assess and verify the ability of providers to deliver services in accordance with the pure form of the ASAM Criteria, as reflected by the rating elements. Therefore it is important to hear the expectations directly from ASAM. ASAM may from time to time publish other resources that your organization may find useful.

    Once your organization has a solid understanding of what it must demonstrate to satisfy the rating elements, it should conduct a review of its program within the context of the elements for each Level of Care to be surveyed. This process is, in essence, a self-conducted mock survey. During this process, compare your organization’s policies, procedures, and other documentation to the specific requirements of the elements. You may notice that there are items that are not completely aligned with the certification elements. If you identify gaps, your organization is encouraged to address them immediately by making the changes necessary to conform to the elements. Anything that can be addressed should be addressed before the survey to minimize the number of elements that may be cited by the surveyor.

    During the survey, the surveyor will select active clinical records to review for each Level of Care to be surveyed and will also ask your organization to select closed records for each of those Levels of Care. Accordingly, prior to the survey you will want to locate active and closed clinical records for each Level of Care for which your organization applied. For example, if your organization applied for Levels of Care 3.7 and 3.5, you should have readily available to the surveyor records of patients admitted to and provided care in Level 3.7, both active and closed, as well as records of patients admitted to and provided care in Level 3.5, both active and closed. Every record should contain the results of the assessment, the treatment plan, and all other documentation specified by the elements to be contained in the clinical record. Again, this applies for all Levels of Care included the survey and those records should be identified and available to the surveyor upon request during the survey.

    Survey Process

    Technology Preparation

    At this time, each certification survey utilizes Microsoft Teams® (Teams). Teams is a unified communication and collaboration platform that facilitates the activities of the survey, including live video and file storage. Accordingly, your organization must have reliable high-speed internet service (at least 25 Mbps recommended) and a desktop or laptop computer capable of operating Teams. Preferably, the organization will have at least one desktop or laptop computer and one or more mobile phones or tablets. At least one device must be mobile with video capabilities (laptop, tablet or mobile phone). Teams is secured by end-to-end encryption.

    Shortly following the scheduling of the survey, CARF will contact the organization to determine whether any organizational staff other than the Survey Key Contact should be added as Teams guests to upload written materials (see Site Preparation, below). Thereafter, the Survey Key Contact and any other identified guests will receive an email notification from Microsoft to join Teams.

    During the period from receiving the Teams notification to the pre-survey contact from the surveyor (approximately 30 days prior to the survey), the organization should:

    • Enable Teams on all devices the organization will use during the survey. CARF recommends using the Teams application on all devices.
    • Sign in to Teams. If the Teams notification was sent to an email account that already has a Microsoft Teams or Office 365 account established, use that account to sign in. If not, establish a free Teams account utilizing the email address that received the notification.
    • Become familiar with and test Teams. The survey will utilize the following Teams functionality: team “General” and “Organization” channels; and meetings (live video, audio and screen share). Recommended video training includes: Join a Teams meeting; Upload and share files; Join a meeting on the go; and Show your screen during a meeting. Accessibility support for Teams is also available.
    • Participate in an interactive training module to guide the use of Teams preparation for the survey.
    • Review the Frequently Asked Questions for using Teams. For support using Teams in connection with your survey, if necessary, contact CARF at extension 7080 or email LOCCertification@carf.org.
    • Depending on the needs of the organization and to provide communication alternatives in the unlikely event there are challenges during the survey using Teams video or audio, the organization may wish to consider enabling its devices with Google Duo® and/or FaceTime® to supplement Teams for some meetings. Both Google Duo and FaceTime are secured by end-to-end encryption.
    • Identify and locate all written materials that demonstrate satisfaction of the applicable rating elements. Any documentation that does not exist in an allowable electronic format under 15GB (other than clinical records) should be scanned or otherwise converted to an allowable format with a file size under 15GB. Wherever possible, the organization should save each electronic document using a file name that includes both the element number(s) to which it relates and the name of the plan, policy, procedure or other document.

    Pre-Survey Contact

    Approximately 30 days prior to the survey, the surveyor will meet with the organization via Teams. The surveyor will work with the organization in advance to schedule and arrange the meeting. The pre-survey contact includes:

    • Confirming the location and Level(s) of Care to be surveyed.
    • Confirming that the organization has addressed each and every defining element for the Level(s) of Care to be surveyed.
    • Confirming the survey date(s) and start time.
    • Confirming the organization has sufficient familiarity with Teams to conduct the survey.
    • Confirming how technology will be used for each survey activity (see Site Preparation and The Survey, below).
    • Determining any additional organizational staff to add as a Teams guest to upload written materials (see Site Preparation, below).
    • Determining whether Google Duo and/or FaceTime will be utilized on any devices to supplement Teams during the survey.

    Site Preparation

    During the period starting immediately after the pre-survey contact to five (5) days prior to the survey, the organization must:

    • Review the General channel in Teams for any information posted.
    • Upload to the Organization channel in Teams all written materials that demonstrate satisfaction of the applicable rating elements, using folders to organize documentation by rating elements subsections of the certification manual (Level 3.1, Section 1A – Setting, Level 3.5, Section 2B – Support Systems, etc.). The organization should also upload a sample clinical record, including but not limited to assessment and treatment plan templates. CARF may cancel or reschedule the survey if all necessary documentation is not uploaded to Teams at least five (5) days prior to the survey. CARF will delete all uploaded materials following issuance of the certification decision. DO NOT send any documentation to the surveyor via email or any method other than uploading to Teams.
    • Notwithstanding the foregoing, DO NOT upload any clinical records or other protected health or personal information. If any written materials that demonstrate satisfaction of applicable rating elements (other than clinical records) includes protected health or personal information, the organization should redact such information prior to uploading to Teams.
    • Upload to the Organization channel in Teams a list of the records numbers of all current patients. If the records are not identified by numbers agnostic of protected health or personal information, the organization should prepare a list of the names or dates of birth of all current patients, which list will be viewed by the surveyor during the survey; DO NOT upload the names or dates of birth to Teams.
    • Select and scan the complete closed clinical records for at least five (5) patients post discharge/transition. DO NOT upload the closed clinical records to Teams.

    The Survey

    The survey activities include:

    • The surveyor will start the survey at the time determined during the pre-survey contact, typically around 8:00 a.m. The brief orientation includes introductions, an overview of the survey activities, and review of the survey logistics discussed during the pre-survey contact.
    • Organization tour. The organization will guide the surveyor through a tour of all areas of the facility identified by the surveyor, including but not necessarily limited to: (1) building exterior, including street address display; (2) outside spaces available for patient use, including recreation activities; (3) monitoring and security of outside areas; (4) reception area for patients; (5) spaces for individual, group, and family therapy; (6) location of daily schedule, if posted; (7) meal area; (8) location of meal plan, if posted; (9) quiet spaces available for patient use; (10) visitation areas; (11) areas for staff supervision of patient activities, including cameras, monitoring stations, and other supervision methods, as applicable; (12) areas for awake night staff; (13) areas for Level 3.7 nursing staff, if applicable; (14) areas between Level 3.7 nursing staff and patient sleeping areas, if applicable; (15) patient sleeping areas; (16) storage area for patient belongings; and (17) bathrooms for patients based on gender, age, and needs.
    • Document review. The surveyor will independently review organizational documentation, with priority consideration of the defining elements.
    • Preliminary findings for defining elements. Once preliminary findings are determined for the defining elements based on the information available, the surveyor will inform the organization of any defining elements for which sufficient evidence of satisfaction is not yet demonstrated. This will typically occur prior to 1:00 p.m. The goal is to allow an opportunity to produce any information necessary to satisfy all of the defining elements. At that time, the organization will have at least one hour to produce, identify, direct the surveyor to, or otherwise provide additional information that could affect the ratings for the defining elements. During this one-hour period, the surveyor will continue to review documents related to the non-defining elements and begin reviewing clinical records.
    • Clinical records review. The organization will guide the surveyor through a review of clinical records.
    • Wrap-up. After considering any additional information presented with respect to the preliminary findings for defining elements, the surveyor will conduct a brief wrap-up meeting during which the surveyor will identify any defining elements rated as not satisfied. No additional information may be presented at this time. The certification decision will not be communicated during the wrap-up meeting, as CARF does not apply the scoring methodology until it receives the survey findings from the surveyor. However, since all defining elements for a Level of Care must be met to receive certification for that Level of Care, the identification of any defining elements during the wrap-up meeting will be instructive. The surveyor will then thank you for your participation and conclude the survey.

    Technology will be used to perform the survey activities, based on the pre-survey contact, as described below:

    • The orientation, guided organization tour, meeting to discuss preliminary findings for defining elements, and wrap-up meeting will be performed using live video and audio on a device enabled with Teams, Google Duo or FaceTime. Traditional telephone calls may alternatively be used for the orientation, meeting to discuss preliminary findings for defining elements, and the wrap-up meeting.
    • The review of written documentation (excluding clinical records) will be performed independently by the surveyor using the Teams Organization channel. Knowledgeable staff should be available at the surveyor’s request to facilitate the review of documentation using live video or audio on a device enabled with Teams, Google Duo or FaceTime.
    • The guided clinical records review, including the sharing of any lists of names of patients, will be performed using live video, audio, and screen sharing on a device enabled with Teams, or live video and audio on a device enabled with Teams, Google Duo or FaceTime. Knowledgeable staff should facilitate the surveyor’s review of clinical records. Be prepared to scan for screen sharing all clinical records identified by the surveyor for review during the survey.
    • As the surveyor schedules the orientation, guided organization tour, meeting to discuss preliminary findings for defining elements, and the wrap-up meeting, the Survey Key Contact should forward each meeting notification email to the appropriate organizational stakeholder (if other than the Survey Key Contact). The Survey Key Contact should also forward the clinical records review meeting notification to the staff who will facilitate the surveyor’s review.
    • If the survey is scheduled for two days, at the end of the first survey day the surveyor will communicate to the organization the progress of the survey and the next day’s activities using live video or audio on a device enabled with Teams, Google Duo or FaceTime. A traditional telephone call may alternatively be used.

    It is the responsibility of the surveyed program to demonstrate that it satisfies the certification elements. Success depends on your ability to show the surveyor that the program satisfies the rating elements. It is not the surveyor's responsibility to find and tease out every single thing. You should be able to say, "We understand the Level of Care. We understand what the expectations are for delivering this Level of Care, and we have built both a clinical and administrative infrastructure that support the delivery of that particular Level of Care."

    The surveyor will do his or her best to try to help you to be successful, based on the information you present. The surveyor may ask questions about certain documents or have you locate specific things that he or she is not able to find. The expectation, however, is that you have all information available and ready for the surveyor prior to the survey. At worst, you must be able to readily produce upon request any information requested to demonstrate satisfaction of the rating elements.

    After the Survey

    After the survey, the surveyor will submit the survey findings to CARF and CARF will determine the certification decision based on whether, for each Level of Care surveyed, your organization met all of the defining elements and demonstrated substantial satisfaction of the nondefining elements. If CARF issues certification for one or more Levels of Care, the certification is effective for three years.

    If your program is certified, it must submit a plan of action (POA) to CARF within 90 days of receiving the certification decision. The POA must address all the elements that were not satisfactorily demonstrated during the survey. Certified programs must also submit an annual report to CARF that certifies their ongoing satisfaction of the elements. CARF will send the report form for completion prior to each anniversary following the issuance of certification.

    Programs not issued certification will also receive a POA to identify the elements not met and the areas that should be addressed in any future certification efforts.

    Thank You

    If you have questions about the elements and how to meet them, visit ASAMcertification.org or contact ASAM at certification@asam.org. If you have any questions about the certification process, please contact CARF’s certification support team at LOCCertification@carf.org or 888-281-6531 extension 7080. Again, thank you for your commitment to obtaining CARF certification of your organization’s ASAM Levels of Care, and for taking the time to maximize the likelihood of success. Good luck with your survey!

    Effective July 17, 2020

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