016.04.96 Ark. Code R. § 001 - Accreditation Policy for Certified Community Mental Health Centers and Clinics

I. All Community Mental Health Centers or Clinics presently certified by the Division of Mental Health Services under the Standards For Community Mental Health Centers And Clinics In The State Of Arkansas must seek and attain accreditatidrrhy eitherj~£__^^ Commission on Accreditation of Rehabilitation Faculties (CARF) or the Joint CorSrrisston on Accreditation of Healthcare Organizations (JCAHO) in order to continue iecsrvmg funding under contract with the Division of Mental Health Services and/or to raamtain designation as a certified Community Mental Health Center or Clinic.
A The Accreditation Survey must take placi within 18 months of the eff?01?6 date of this policy.
B. All Community Mental Health Centers or Clinics will be expected to sc}ect m accreditation model and provide notification of this choice to the Divi?10n ° Mental Health Services within 90-days of the effective date of this pollcy-
C. Community Mental Health Centers or Clinics who are Non-Accrediter *W CARF or JCAHO will not be eligible to contract with the Division of MentalHealm Services.
D. The certified Community Mental Health Center or Clinic must be accredited m ^ program elements currently covered by the Standards For Cornmnntty Health Centers And Clinics In The State'Of Arkansas. 1990, that wou1? De applicable to the status (community mental health center or clinic) app1 ec* "[GREATER THAN]r through the Division of Mental Health Services.

Program areas for services include, but are not limited to:

1. Emergency Services.
2. Partial Care Services including partial care and day treatment ?rog13111^ including clubhouse programs.
3. Outpatient Services.
4. Consultation, Education, and Prevention.
5. Follow-up and Aftercare Services.
6. Initial Screening and Precare Services, and
7. A Community Support System.
E. Affiliates must be accredited by CARF/JCAHO in those elements of service for which they contract with the Community Mental Health Centers. Affiliates providing services not covered or requiredjby the contract between the Division of Mental Health Services and the Community Mental Health Center or Clinic are exempt from this policy.
F. The Division of Mental Health Services may establish additional standards or require organizations to meet additional standards that have a basis in law and/or regulation, in the event that these requirements are not addressed by the accrediting body.
II. Costs

Community Mental Health Centers or Clinics or their affiliates will be responsible for all costs associated with accreditation including written materials, manuals, technical assistance, training, application and surveyor fees, etc. No accreditation costs will be paid by the Division of Mental Health Services.

III. Reporting
A. Organizations will submit to the Division'', of Mental Health Services a copy of the accrediting body's written survey report 01 re-survey reports within 30-days of the receipt of the report. This report should'in elude:
1. The accrediting body's conclusions regarding the award or denial of accreditation status.
2. Any terms or requirements the organizations must meet as a condition for achieving or maintaining accreditation status.

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3. Deficiencies or recommendations.
B. When the accrediting body requires a corrective action plan and/or periodic written progress reports to address identified needs/recommendations that are conditions for attaining or maintaining accredited status, a copy of this plan and all subsequent reports shall be submitted to the Division of Mental Health Services.
C. Identification of problem areas any time during the accreditation period may result in corrective action by the Division of Mental Health Services.
IV. CARF
A. Possible Outcomes

Tlie CARF accreditation process offers four (4) possible survey outcomes: Three-Year Accreditation; One-Year Accreditation; Provisional Accreditation; and Non-Accreditation. There is one (1) other survey outcome option available: Twelve-Month Abeyance. The Division of Mental Health Services shall accept that a Community Mental Health Center or Clinic is certified as a Community Mental Health Center or Clinic if it receives;any survey outcome other than Non-Accreditation. A Community Mental Health Center or Clinic whose survey results in an "Abeyance" decision shall be considered accredited for the purposes of being eligible for a Division of Mental Health Services' contract during the time of the abeyance. However, an agency must become accredited during the Twelve-Month Abeyance process to be eligible for subsequent Division of Mental Health Services' contracts. EXPLANATION: Due to the presence of conditions affecting the service benefits, health, welfare or safety of persons served, an organization may ? fall short of a One-Year Accreditation. When CARF recognizes a willingness and capability of an organization to correct such existing conditions, then the decision to accredit or not accredit will be delayed until the organization is provided up to twelve (12) months to correct the problems. This is a "one-time only" abeyance, and is not available to currently CARF accredited organizations.

V. JCAHO -
A. Possible Outcomes

The JCAHO accreditation process offers five (5) categories of accreditation decisions: Three-Year Accreditation with Commendation; Three-Year Accreditation With Or Without Type 1 Recommendations; Conditional Accreditation; Provisional Accreditation;'and Not Accredited. The Division of Mental Health Services shall accept that a Community Mental Health Center or Clinic is certified as a Community Mental Health Center or Clinic if it receives any survey outcome other than Provisional Accreditation or Not Accredited. If a Community Mental Health Center or Clinic receives an Accreditation With Type 1 Recommendations, or a Conditional Accreditation, it shall be deemed to be certified during that period pending results of follow-up monitoring conducted by the accrediting body. i

B. Organzations receiving accreditation with Type 1 Recommendations risk loss of accreditation if the recommendations are not resolved within a period of time specified by JCAHO. Improvement in these areas is monitored and assessed through the use of focused surveys or written progress reports. Organizations receiving Accreditation With Type 1 Recommendations will not be in jeopardy of loss of contract during this monitoring period.
C. Conditional Accreditation indicates that multiple substantial standards compliance deficiencies exist in an organization or that the organization has not corrected Type 1 Recommendations in the timeframes specified. Organizations in this status are required to develop a plan of correction and demonstrate sufficient improvement in a follow-up survey within'six (6) months. Community Mental Health Centers or Clinics shall be considered accredited for the purposes of being eligible for a Division of Mental Health Services' contract during the time pending results of the follow-up survey.
D. Provisional Accreditation is granted when an organization has demonstrated substantial compliance with selected structural standards surveyed in the first of two surveys conducted under the Early Survey Policy. The second survey is conducted approximately six (6) months later to allow sufficient time to demonstrate a track record of performance. Provisional Accreditation status remains until the organization completes'the second full survey. The Early Survey Policy is available to new organizations that would like to be accredited but are not ready for a full evaluation, to organizations in operation less than four (4) months, and to organizations undergoing their first JCAHO survey. Community Mental Health Centers or Clinics shall not be considered accredited for the purposes of being eligible for a Division of Mental Health Services' contract during the time of Provisional Accreditation. A Communiry Mental Health Center or Clinic shall be considered accredited for the purposes of being eligible for a contract if a decision of accreditation status other than Not Accredited is awarded after a second survey.
VI. Evaluation Process

The Division of Mental Health Services may establish a process to monitor services provided by the Community Mental Health Centers or Clinics through the ongoing collection- of uniform, objective performance data.

Notes

016.04.96 Ark. Code R. § 001
3/8/1996

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