Digitally Enabled Site Survey program

CARF’s Digitally Enabled Site Survey program (DESS), described below, is in effect until further notice. DESS participation is determined in CARF’s sole discretion.1

Technology preparation

Each DESS survey utilizes Microsoft Teams® (Teams). Effective use of Teams requires that your facility has reliable high-speed internet service (at least 25 Mbps recommended) and a desktop or laptop compatible with Teams. Preferably, you will have at least one desktop or laptop and one or more mobile phones or tablets. At least one device must be mobile with video capabilities (laptop, tablet, or mobile phone).

Shortly after scheduling the survey, CARF will ask you to identify any staff other than the Survey Key Contact and Accreditation Liaison who should be added as Teams guests to upload documentation (see the Site preparation section below). Thereafter, the Survey Key Contact and any other identified guests will receive an email notification from Microsoft to join Teams. Once you receive the Teams notification and before the pre-survey meeting (see the Pre-survey contact section below), you should:

  • Enable Teams on all devices you will use during the survey. CARF recommends using the Teams application.
  • Sign in to Teams. If the Teams notification was sent to an email account that already has a 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 (approximately 30 minutes) to guide the use of Teams preparation for the survey. Note: The module is best viewed when using Microsoft Edge, Google Chrome, of Safari web browsers.
  • 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 asc@carf.org.
  • Depending on the needs of the organization or the persons to be interviewed during the survey and to provide communication alternatives in the unlikely event there are challenges during the survey using Teams video or audio, you may wish to consider enabling all devices with Google Meet® and/or FaceTime® to supplement Teams.
  • Identify and locate all written materials that demonstrate standards conformance, including but not limited to all documentation specified in Appendix A of the applicable standards manual. Any documentation that does not exist in a supported electronic format under 100 GB (other than records of persons served) should be scanned or otherwise converted to a supported format with a smaller size. Wherever possible, the organization should save each electronic document using a file name that includes both the standards number(s) to which it relates and the name of the plan, policy, procedure or other document.

Pre-survey contact

Approximately 20 days prior to the survey, the survey team coordinator will meet with you via Teams. The survey team coordinator will work with the organization in advance to schedule and arrange the meeting. In addition to the usual and customary topics of the pre-survey contact, the DESS pre-survey contact also includes:

  • 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 Digitally Enabled Site Survey sections below).
  • Determining any additional organizational staff to add as a Teams guest to upload documentation (see the Site Preparation section below).
  • Determining survey room needs (see the Site Preparation section below).
  • Determining whether Google Meet and/or FaceTime will be utilized on any devices to supplement Teams during the survey.

Site preparation

After the pre-survey contact and at least five days before the survey, you must:

  • Review the General channel in Teams for posted information.
  • Upload to the Organization channel in Teams all written materials that demonstrate standards conformance, using folders to organize documentation by subsection of the standards manual. In addition to any other documentation that demonstrates conformance, you must include all documentation specified in Appendix A of the applicable standards manual. You should also upload a mock person served 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 days before the survey. All uploaded materials will be deleted after the issuance of the accreditation decision. DO NOT send any documentation to the survey team through email or any method other than uploading to Teams.
  • Do NOT upload any records of persons served or other protected health or personal information. If any documentation includes protected health or personal information, you must redact such information before uploading.
  • Upload to the Organization channel in Teams a list of the record numbers of all current persons served and at least five former persons served (excluding Preliminary surveys2). If the records are not identified by numbers agnostic of protected health or personal information, prepare a list of the names or birthdates of all current persons served and at least five former persons served for the survey team to view during the survey (if applicable); Do NOT upload the names or birthdates to Teams.
  • Establish one or more rooms at the organization, as determined during the pre-survey contact, within which appropriate organizational staff, leadership, persons served and other stakeholders will participate in the orientation and exit conferences, pre-exit meeting (if requested), interviews and the survey team’s review of records of persons served and other written documentation. Each room should contain an appropriate device enabled to operate Teams, Google Meet and/or FaceTime, as determined during the pre-survey contact. For the interview room(s), provide for privacy and confidentiality.
  • To supplement the survey poster, effectively communicate in a way that is understandable to persons served that the survey will be conducted using live video and audio technology. Also make best efforts to mitigate any anxiety that may be associated with the use of technology during the survey using reasonable measures based on the strengths, needs, abilities and preferences of the persons served.

Digitally Enabled Site Survey

The survey team will conduct the site survey (including the schedule of survey activities) consistent with the process published in the standards manuals, to the extent possible. Technology will be used to perform the survey activities, based on the pre-survey contact, as described below:

  • As the survey team schedules the organization tour, orientation and exit conferences, the pre-exit meeting (if requested), observation of services and interviews, the Survey Key Contact should forward each meeting invitation email to the appropriate organizational staff, leadership, persons served or other stakeholders. You should also forward meeting invitation(s) to the staff who will facilitate the survey team’s review of records of persons served and other written documentation. For persons served identified by the survey team for interview who will not utilize a survey room established for that purpose, provide contact telephone numbers to the survey team.
  • The orientation and exit conferences, pre-exit meeting (if requested) and interviews will be performed using live video or audio on a device enabled with Teams, Google Meet or FaceTime. Traditional telephone calls may also be appropriate for some survey activities. 
  • The organization tour and observation of services will be performed using live video on a mobile device enabled with Teams, Google Meet, or FaceTime. If applicable, evening hours may be used for tours of residential, housing, living, or similar locations.
  • The review of records of persons served, including the sharing of any lists of names of persons served (if applicable), will be performed using screen sharing on a device enabled with Teams or live video on a device enabled with Teams, Google Meet, or FaceTime. Knowledgeable staff should facilitate the survey team’s review of records of persons served.
  • The review of other written documentation will be performed using the Teams Organization channel. Knowledgeable staff should be available to facilitate the survey team’s review of documentation using live video or audio on a device enabled with Teams, Google Meet or FaceTime.
  • At the end of each survey afternoon other than the last day, the survey team will communicate the progress of the survey and the next day’s activities using live video or audio on a device enabled with Teams, Google Meet or FaceTime.

Rules of participation

The following rules apply to DESS participation:

  • The organization will in good faith satisfy all DESS requirements set forth herein.
  • The Accreditation Policies and Procedures published in the primary standards manual under which the survey is conducted apply to the extent not inconsistent with DESS.
  • CARF may conduct a subsequent on-site survey at any time for any reason during the term of accreditation following a DESS survey. In the event CARF elects, prior to issuance of the accreditation decision, to require a subsequent on-site survey, the accreditation decision will be withheld pending the subsequent on-site survey.
  • CARF may change the survey timeframe for any eligible survey at any time upon notice to the organization.
  • If CARF cancels or reschedules the survey for failure to timely upload documentation to Teams, CARF will assess a cancellation/rescheduling fee.
  • CARF may modify or terminate DESS at any time, with or without notice.
  • Any and all matters related to DESS, including but not limited to application, eligibility, implementation and interpretation, will be determined in CARF’s sole discretion.

Questions

Contact your Resource Specialist if you have any questions about DESS.

  1. For on-site surveys, the pre-survey contact and one or more survey activities may be performed in accordance with DESS, as determined by CARF. The applicable requirements set forth herein apply to each such activity. ↩︎
  2. See the Preliminary Accreditation Guidelines. ↩︎