Frequently Asked Questions
How is an accreditation score calculated?
- Staff Qualifications
- Staff Training
- Treatment Programming
- Accessibility of Services
- Social Media & Online Presence
- Consumer Satisfaction
- Staff Satisfaction
These areas are measured using a qualitative semi-structured interview with the agency clinical leadership, a detailed staff qualification review, an examination of documents, and two anonymous staff satisfaction and consumer satisfaction surveys.
What are the possible accreditation decisions?
If a provider scores below 85%, they will be granted a provisional accreditation lasting 6 months and provided with a performance improvement plan. The performance improvement plan will outline performance improvement areas and supported documentation needed to show improvement after 6 months. You may consult with your evaluator to discuss suggestions for improvement or best practice strategies. If you wish to receive coaching, BHCOE can recommend external organizational consultants that can assist with preparation for your re-evaluation.
How are BHCOE standards developed?
The Behavioral Health Center of Excellence Accreditation Program (BHCOE) is required to comply with the essential requirements and policies of ANSI for American National Standards (ANSI) Developers. These requirements are defined in “ANSI Essential Requirements: Due process requirements for American National Standards”. Where the BHCOE Operating Principles and Procedures are silent on an issue, the American National Standards Institute’s (“ANSI”) Essential Requirements document referenced above shall serve as the precedent document.
The BHCOE accreditation process evaluates ABA organizations against standards available via peer reviewed literature, best practice literature and state and federal law. The Code was established by the BHCOE reflect the best practices established by the field of ABA. The Code is comprised of the Preliminary Accreditation Standards and the Full Accreditation Standards. The BHCOE evaluation tool measures Compliance with these Codes.
Codes are developed by the BHCOE Commission. The BHCOE Commission is responsible for developing new or revised language for the Code, as these Codes fall within the scope of these procedures. The BHCOE Commission is organized by the BHCOE Standards Coordinator. Additionally, the BHCOE Standards Coordinator will coordinate Subcommittees, when needed. The BHCOE Commission will maintain and keep current the process, appeals, interpretations, self-assessment guidance and other training and education activities relevant to the Code. The BHCOE Standards Coordinator, BHCOE Commission and Subcommittees must comply with the ANSI requirement for openness, balance and due process.
The BHCOE Commission will also serve as the “consensus body” for the purpose of documenting consensus on all American National Standards proposed by BHCOE.
The Commission is composed of a minimum of ten commissioners who are appointed by BHCOE; Commissioners represent a broad spectrum of public, private and general interest groups.
The ten commissioners represent the following types of organizations.
1. Patient Advocate or Patient Representative (2)
2. Trade Association Representative (1)
3. Private Insurance Representative (1)
4. Public Insurance Representative (1)
5. Academic from Applied Behavior Analysis/field (1)
6. Private sector organizational representative of varying sizes (3)
7. Local State ABA Chapter representative (1)
How much does accreditation cost?
Who completes the evaluation?
What about HIPAA?
What about HIPAA?
As clinical auditors, we will have access to protected health information (“PHI”) collectively referred to as “HIPAA.” The clinical auditor agrees to fully comply with requirements under HIPAA, throughout the term of the clinical audit. Further, every agent, employee, subsidiary, and affiliate of the Behavioral Health Center of Excellence to whom PHI is received will be required to fully comply with HIPAA, and will be bound by written agreement to the same restrictions and terms and conditions.
Your clients are protected under section 45 CFR 164.506 of the HIPAA Privacy Rule in which:
“Health care operations” are certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support the core functions of treatment and payment. These activities, which are limited to the activities listed in the definition of “health care operations” at 45 CFR 164.501, include:
- Conducting quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, and case management and care coordination;
- Reviewing the competence or qualifications of healthcare professionals, evaluating provider and health plan performance, training health care and non-health care professionals, accreditation, certification, licensing, or credentialing activities”
“Health care operations” are certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support the core functions of treatment and payment. These activities, which are limited to the activities listed in the definition of “health care operations” at 45 CFR 164.501, include: Conducting quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, and case management and care coordination; Reviewing the competence or qualifications of health care professionals, evaluating provider and health plan performance, training health care and non-health care professionals, accreditation, certification, licensing, or credentialing activities”
In addition consumers are notified prior to survey administration that the response to the survey is voluntary and will not affect their services in any way. They are also provided with an “opt out” option at the initial point of contact.
What about the BACB?
The Behavior Analyst Certification Board® (BACB®) certifies individual behavior-analytic practitioners, whereas BHCOE accredits organizations who may employ those individuals.
Does BHCOE provide any help in preparing for a survey?
Do we have to submit all our programs for accreditation?
Can BHCOE accredit services provided by an individual?
Why are evaluation interviews recorded?
Recording the evaluation is an important component of BHCOE’s internal quality assurance process. BHCOE regularly conducts inter-observer agreement (IOA) on evaluations to ensure that findings are scored fairly and appropriately. This helps our organization maintain a high standard of reliability in our accreditation scoring process.
What are the financial benefits of BHCOE Accreditation?
What happens if my organization does not agree with BHCOE's accreditation decision results?
Organizations that the BHCOE has conducted a review of and that have received a Preliminary
Accreditation, Full Accreditation, Provisional Accreditation or Non-Accreditation may appeal the
BHCOE to re-score their accreditation review within 30 days of completion of the review. All documentation is reviewed by an alternate auditor and confirmed by the Appeals Committee. All appeal decisions are final.
How Can I Get Involved?
The Behavioral Health Center of Excellence is looking for community members interested in serving on our Community Advisory Board (CAB). The CAB represents the applied behavior analysis community as clinicians, academics, and ABA agency owners. To learn more, please send your CV to firstname.lastname@example.org.