ACCREDITATION DECISIONS

Preliminary Accreditation

Preliminary Accreditation occurs for newer organizations or organizations preparing to meet full accreditation review within a year, prior to a full evaluation. This consists of a high-level review of organizational systems to identify areas for improvement prior to growth. Preliminary accreditation consists of an interview, document review and systems analysis. NOTE: Preliminary accreditation can also be used by providers looking to prepare for full accreditation within the next year as a way to prepare for the larger survey.

Full Accreditation

Occur every 1- 3 years, dependent on the organization’s score. This review conducts a full review of laws and regulations, billing and organizational systems, clinical standards, reporting, client outcome, staff turnover, and consumer satisfaction. The full accreditation consists of a site visit, clinical observation, interview, document review, survey of staff and consumers and systems analysis.

Three-Year Accreditation

The organization satisfies 96%-100% of the accreditation standards. The organization has demonstrated their policies and procedures are applied effectively. The organization has demonstrated significant improvement from previous BHCOE Accreditation evaluations.

Score: 96%-100%

Two-Year Accreditation

The organization satisfies 91%-95% of the accreditation standards. The organization has demonstrated their policies and procedures are applied effectively. The organization has demonstrated significant improvement from previous BHCOE Accreditation evaluations.

Score: 91%-95%

One-Year Accreditation

The organization satisfies 85%-90% of the accreditation standards. The organization has demonstrated their policies and procedures are applied effectively. The organization has demonstrated significant improvement from previous BHCOE Accreditation evaluations. The organization demonstrates a commitment to correct the deficiencies revealed to further establish compliance with the Standards.

Score: 85%-90%

Interim Annual Reviews

Interim Annual Reviews: Occur annually for 2 or 3-year accredited organizations to maintain accredited status between full accreditation reviews. This review entails an update of any law and regulation changes, review of changes to leadership personnel practices to ensure continued compliance with the accreditation standards and to identify areas of improvement.

Provisional Accreditation

If the participating provider receives a score less than 85%, the provider will earn a provisional accreditation and will receive a Quality Improvement Plan (QIP) to assist the provider in adjusting their organizational practices. It is requested that these adjustments be made within 3-6 months following the receipt of the plan. After 3-6 months, the provider is then re-assessed in the areas addressed in the QIP.

Non-Accreditation

The organization has extensive areas of improvement in numerous areas of the standards and there are questions about the benefit of services or welfare of those served or employed by the organization. The organization has failed to bring itself to significant conformance to standards, or the organization has falsified documentation or information provided to BHCOE.

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