If you are a facility either approved by CARF and JCAHO or you are working to become approved, you need annual inspections done by a qualified and certified inspector.
CARF is the Commission on Accreditation of Rehabilitation Facilities. JCAHO is the Joint Commission’s term used for Accreditation.
All facilities are required to be inspected once every year. The CARF inspection is defined in para. 1.H.13 and is reprinted here:
CARF HEALTH AND SAFETY ANNUAL INDEPENDENT INSPECTION
1.H.13. Comprehensive health and safety inspections:
a. Are conducted:
(1) At least annually.
(2) By a qualified external authority.
b. Result in a written report that identifies:
(1) The areas inspected.
(2) Recommendations for areas needing improvement.
(3) Actions taken to respond to the recommendations.
Annual external inspections are completed to enhance and maintain the organization’s health and safety practices. External inspections must include all facilities regularly utilized by the organization.
External inspection by a compliance/safety officer may include:
• A representative of the fire department.
• A representative of a local health department.
• A licensed or registered safety engineer.
• A representative of a state, provincial/territorial, or federal agency that provides OSHA, health, or physical plant inspections on a consultative or licensing basis. In Canada, this could include a representative from a provincial/territorial body designated under legislation related to workplace safety.
• An engineer involved in industrial operations. This person is knowledgeable regarding the health and safety requirements applicable to the services provided.
• A plant engineer or safety specialist.
• A safety consultant who represents the organization’s fire or workers’ compensation carrier or who is in private practice.
• An industrial health specialist.
• A representative of the organization’s insurance carrier or a private insurance carrier.
In those instances in which the program is provided by a unit of a larger entity, such as a hospital, the larger entity’s safety engineers or other personnel are not considered external authorities. External means external to the entire system, not just to a unit of the organization. Exceptions include some settings such as Veterans Health Administration or Veterans Affairs Canada sites, other federal or tribal programs, and government-owned organizations where certain functions may be conducted by departments within the larger organization.
In these instances, the organization should contact the CARF office. Any external authority used by the organization (e.g., a representative of a licensure body) should be recognized and credentialed as such (e.g., a licensed or registered safety engineer or risk management authority).
The externally conducted inspections may include inspections of:
• Emergency warning devices, means of egress, and emergency plans.
• Operations involving hazardous materials and processes, including the safe and effective management of biohazard materials.
• Heating and cooling systems.
• Walking and working surfaces.
• Electrical systems.
• Health and sanitation provisions with regard to food preparation, eating areas, and air contaminants.
• The working environment, including ventilation, illumination, noise, and air contaminants.
• Structural integrity of facility.
• The provisions for fire protection to ensure that they are in accordance with applicable state, provincial/territorial, and local fire safety requirements.
• Operation of machinery.
13.a.(1) One comprehensive external inspection is the minimum requirement of the standard. This inspection may be conducted in a single, uninterrupted process that moves methodically and comprehensively through an entire program area or physical location, or the organization may have several external inspections conducted that together constitute a comprehensive inspection of all areas relevant to the operation of its programs or services.
Here is a sample checklist for CARF inspections.
SAFETY – INTERNAL INSPECTION CHECKLIST
Inspection #:__________ Shift:______________
Site Health and Safety Binder present and accessible?
NOTE: All boxes not marked require a response and corrective action.
1. Main Entrance
a. Free of clutter/unobstructed
b. Doors unlocked
a. Marked and accessible with lite Emergency Signs and Lighting
b. Passageways leading to exits are completely clear
c. Internal doors leading to exits are all unlocked
3. Fire Extinguishers
a. Are available at main building exits and operational
b. Are labeled and up-to-date
4. Fire, Smoke, and Carbon Monoxide Detectors
a. Fire alarms are operational
b. Smoke detectors located in each room and operational
c. Carbon Monoxide detectors are locate on each floor and operational
5. First Aid Kit (s) and Disaster Preparedness Kits
a. First Aid Kits on-site, marked and visible
b. Easily accessible to clients and staff
c. Fully replenished
1) Gauze pads (at least 4 x 4 inches).
2) Two large gauze pads (at least 8 x 10 inches).
3) Box adhesive bandages (band-aids).
4) One package gauze roller bandage at least 2 inches wide.
5) Two triangular bandages.
6) Wound cleaning agent such as sealed moistened towelettes.
8) At least one blanket.
10) Adhesive tape.
11) Latex gloves.
12) Instant Ice Pack
13) Resuscitation equipment such as resuscitation bag, airway, or
14) Pocket mask.
15) Two elastic wraps.
17) First Aid Instruction Handbook (Red Cross)
c. Disaster readiness kit is on site
1) Water, one gallon of water per person per day for at least three days, for drinking and sanitation
2) Food, at least a three-day supply of non-perishable food
3) Battery-powered or hand crank radio and a NOAA Weather Radio with tone alert and extra batteries for both
4) Flashlight and extra batteries
5) First aid kit
6) Whistle to signal for help
7) Dust mask to help filter contaminated air and plastic sheeting and duct tape to shelter-in-place
8) Moist towelettes, garbage bags and plastic ties for personal sanitation
9) Wrench or pliers to turn off utilities
10) Manual can opener for food
11) Local maps
12) Cell phone with chargers, inverter or solar charger
a. Available, accessible
b. Contain emergency phone numbers
c. Poison Control number clearly visible
7. Emergency Lighting:
a. On site and operational (back up lighting system or flashlights available in all areas and in working order)
8. Evacuation Diagrams:
a. Located in areas where people congregate, but not an exit
b. Easy to interpret and follow
c. At all required locations
a. Drains in good working order
b. No leaks noted
10. Equipment, Appliances and Machinery
a. Cords and plugs are in good repair and properly grounded
b. No exposed wires
c. No use of extension cords in place of permanent wiring
d. No extension cords under carpet or through ceiling
e. No extension cords in pathways
f. No power strips used in combination with extension cords
g. No refrigerators, copiers, microwaves, space heaters, or coffee makers plugged into a power strip
h. Space heaters at least 2 feet from any wall and 3 feet from a combustible
11. Storage Areas and Closets
b. Locked if contents are dangerous to client’s health and safety
a. Clean and sanitary
b. Pump Soap
c. Paper Towels
d. Afford Privacy
e. Quick Release gain access if needed from the outside
13. Hot Water Heater
a. Temperature set at no greater than 110 degrees
14. Lunch/Break Areas
a. Appliances are in good working order and clean and sanitary
b. Sink, counter, and table are clean
c. Food properly stored
a. Handrails in place
b. Clean/clear and safe walking areas
c. Any low ceiling/overhead is clearly marked
16. Biohazards/Regulated Waste
a. All regulated waste related to blood borne pathogens and medical procedures are discarded and contained according to regulations.
b. All hazardous material containers are labeled appropriately
a. All aisles and passageways are clear
b. Any wet surfaces are covered or marked
c. Holes or cracks in floor are covered and safe
d. Adequate headroom is provided throughout all walkways
e. Any change in floor level is clearly marked and visible
18. Exterior Building
a. Main entrance well marked and visible
b. Buildings and exterior equipment are clean and in good repair
c. No parking on sidewalks
d. Adequate exterior lighting for parking and sidewalks
a. Grass is cut and trimmed
b. Trash is removed
c. Designated smoking areas are identified and away from all entrances
d. Walkways are free of tripping hazards and barriers to wheelchair access
a. Signs and markings identified for handicapped parking areas
b. Clear pathway for wheel chairs from accessible space