Failed My Accreditation Survey for Behavioral Health

Receiving a failed accreditation survey from Joint Commission, ACHC, or CARF for your behavioral health organization can be disheartening and overwhelming. However, it is essential to remember that this setback is an opportunity for growth and improvement. In this blog post, we will guide you through the next steps to take after a failed survey and provide insights on how to navigate the process effectively.

1. Assess and Understand the Findings: The first step is to thoroughly review the survey findings provided by the Joint Commission, ACHC, or CARF. Take the time to understand the specific areas where your organization fell short and the reasons behind it. This assessment will help you gain clarity on the improvements needed and prioritize your actions.
2. Develop an Action Plan: Based on the identified deficiencies, develop a comprehensive action plan that addresses each issue. This plan should outline specific strategies, responsible individuals, and realistic timelines for implementation. Engage your team in this process, as their insights and expertise will be invaluable in devising effective solutions.
3. Seek External Expertise: Consider engaging an external behavioral health consulting firm, like Simplifyance, with expertise in Joint Commission, ACHC, or CARF accreditation.  Our team of consultants has over 80 years of combined experience working in compliance and can provide you with a fresh perspective, in-depth knowledge, and guidance on best practices to meet compliance requirements. Our support can help streamline your improvement efforts and ensure a smoother path toward reaccreditation.
4. Establish a Culture of Continuous Quality Improvement: Use the failed survey as an opportunity to foster a culture of continuous quality improvement within your organization. Encouraging open communication, learning from mistakes, and embracing a proactive approach to compliance. Regularly review policies, procedures, and workflows to identify areas for enhancement and make necessary adjustments.
5. Implement Staff Education and Training: Invest in staff education and training to address the deficiencies identified in the survey. Provide your team with the necessary tools, resources, and knowledge to meet the standards set by the Joint Commission, ACHC, or CARF. Ongoing education and training programs will not only improve compliance but also enhance the overall quality of care delivered to your clients.
6. Engage in Mock Surveys and Self-Assessments: To ensure preparedness for the next accreditation survey, conduct mock surveys and self-assessments regularly. These exercises simulate the actual survey process and allow you to identify any remaining gaps in compliance. Address any deficiencies identified promptly, adjusting your action plan as needed. Simplifyance can be a facilitator for these mock surveys and help your team understand what surveyors will be looking for.
7. Collaborate with Peer Organizations: Reach out to other behavioral health organizations that have successfully gone through the accreditation process or faced similar challenges. Sharing experiences, lessons learned, and best practices can provide valuable insights and support your journey toward reaccreditation.

Failing a Joint Commission, ACHC, or CARF accreditation survey may feel discouraging, but it does not signify the end of the road. By taking proactive steps, seeking external expertise, and fostering a culture of continuous improvement, you can turn this setback into an opportunity for growth and ultimately achieve compliance excellence. Stay committed, engage your team, and remember that the goal is to provide safe and high-quality care to your behavioral health clients.

Remember, you are not alone on this journey. Simplifyance is here to help you to be your partner in offering solutions, building the right strategies, and fostering collaboration so you can successfully address the deficiencies, meet the accreditation standards, and continue your mission of making a positive impact in the lives of those you serve.