Code of Effective Behavioral Organizations
By initiating the BHCOE Accreditation process, the organization acknowledges that they have read and are familiar with the Code of Effective Behavior Organizations for the BHCOE Accreditation process. The outcome of the audit may result in awarding the clinical practices with the Behavioral Health Center of Excellence Accreditation. Receiving the Behavioral Health Center of Excellence Accreditation allows the use of the accreditation badge on marketing material and in press. Any organization who engages in the BHCOE Accreditation process agrees to abide by the (i) BHCOE logo usage guidelines (Guidelines), and (ii) BHCOE Code of Effective Behavioral Organizations (Code). If an organization is found to be out of compliance with the Guidelines and/or the Code, they will be notified by the BHCOE Compliance Department. Upon notification from the BHCOE Compliance Department, the organization agrees to take steps to become compliant with the Guidelines and/or the Code. If the organization does not remedy their noncompliance in a timely manner, then their Accreditation may be suspended or revoked by the BHCOE. The BHCOE has established a compliance, disciplinary review and appeal process for matters of noncompliance.
Preliminary Accreditation Standards
A. General Requirements
A.01 Organization is registered or incorporated.
A.02 Organization has general, property, and liability insurance.
A.03 Organization has a valid business license.
A.04 Organization has a payroll/accounting and record-keeping system and/or software.
A.05 Organization has workman’s comp insurance.
A.06 Organization has an employee handbook.
A.07 Organization has a current working budget and proposed next year budget.
A.08 Organization has a defined organizational structure and hierarchy.
A.09 Organization has job descriptions and expectations for all current positions.
A.10 Organization has minimum qualifications and requirements for each job position.
B.01 Organization has an organization-specific employment application.
B.02 Organization has a templated offer letter.
B.03 Organization has a checklist for new hires.
B.04 Organization conducts background checks.
B.05 Organization has employee performance and evaluation guidelines.
B.06 Organization provides safety/crisis management training to staff who may encounter dangerous behavior.
B.07 Organization trains staff on mandated reporting requirements.
B.08 Organization checks all staff Motor Vehicle records.
C.01 Organization has determined where PHI will be located.
C.02 Organization has an appointed HIPAA privacy/security official.
C.03 Organization has determined how or why PHI will be used or disclosed (e.g. treatment, payment, health care operations, public health reasons, etc.).
C.04 Organization’s email and other electronic communication are HIPAA-compliant.
C.05 Organization’s cloud or server-based storage is HIPAA-compliant.
C.06 Organization has a HIPAA breach policy.
C.07 Organization has a data backup plan.
C.08 Organization has HIPAA compliance training.
D. Intake & Hiring
D.01 Organization has a client intake form & questionnaire.
D.02 Organization has a clients’ rights agreement.
D.03 Organization provides a financial responsibility agreement to patients.
D.04 Organization has a confidential exchange of information policy.
D.05 Organization has a new patient welcome letter.
D.06 Organization has a written standard treatment/operating procedure for ABA services that is provided to new clients.
D.07 Organization has a client home safety checklist.
D.08 Organization has an ABA treatment contract.
D.09 Organization has a parent participation and parent interaction policy.
D.10 Organization has a client illness policy.
D.11 Organization has a fee agreement and payment policy.
D.12 Organization has a new client form and checklist.
D.13 Organization has a Notice of Privacy Practices for clients (HIPAA compliance statement).
E.01 Organization has an assessment report template.
E.02 Organization has a progress report template.
E.03 Organization has a BCBA case note template.
E.04 Organization has a paraprofessional/RBT case note template.
E.05 Organization has a reinforcement assessment system for clients.
E.06 Organization has a data collection system.
E.07 Organization has a caregiver training protocol.
E.08 Organization utilizes a standardized assessment when evaluating clients.
E.09 Organization has a plan for how often they will conduct assessments.
E.10 Organization has a curriculum for developing client programming.
E.11 Organization has a quality assurance officer.
E.12 Organization has guidelines for recommending treatment intensity of services.
E.13 Organization has a fade-out policy.
F. Consumer Protection
F.01 Organization has a conflict of interest policy.
F.02 Organization has guidelines regarding the exchange of gifts, money, or personal fundraising.
F.03 Organization has guidelines for how the organization is represented via social media.
F.04 Organization protects client privacy by refraining from posting client information or photos on social media.
F.05 Organization refrains from soliciting and posting testimonials.
F.06 Organization has written ethical codes of conduct.
F.07 Organization has legal representation.
F.08 Organization has a policy regarding non-evidence-based practices that includes refraining from participating in such practices, resolving conflicts when such practices interfere with ABA services, and educating consumers about how to choose effective services.
G.01 Organization has cyber or data privacy insurance.
G.02 Organization has a fidelity bond in place.
G.03 Organization has abuse prevention policies and procedures.
G.04 Organization has a policy in place to avoid one-to-one situations with patients.
Full Accreditation Standards
1.0 Staff Qualifications, Training & Oversight
1.01 Participating provider employs clinical director-level staff who hold adequate education and qualifications.
1.02 Participating provider employs supervisory staff who hold adequate education and qualifications.
1.03 Participating provider employs direct staff who hold adequate education and qualifications.
1.04 Participating provider tests for clinical competence prior to staff providing treatment to clients.
1.05 Participating provider provides training to ensure competency in clinical tasks (e.g., assessment processes, goal creation, intervention design, progress reporting, etc.) and administrative tasks (e.g., staff training, feedback delivery, BACB supervision standards, ethical billing practice, etc.).
1.06 Participating provider provides staff with continuing education in line with their areas of need.
1.07 Participating provider ensures consistency of treatment across staff members through staff overlap, data collection, and/or team meetings.
1.08 Participating provider will utilize employee performance evaluation processes such as goal-setting, performance measurement, regular performance feedback, and self-evaluation, as evidenced by documentation of employee progress.
1.09 Participating provider defines organizational structure and hierarchy.
1.10 Participating provider provides job descriptions and expectations for all current positions.
2.0 Treatment Program & Planning
2.01 Participating provider utilizes standardized assessments to evaluate client outcome annually, or more frequently if needed.
2.02 Participating provider collects and monitors individual outcome data.
2.03 Participating provider collects and monitors organizational outcome data.
2.04 Participating provider utilizes evidence-based curricula when developing client goals.
2.05 Participating provider utilizes research-based skill-acquisition procedures.
2.06 Participating provider utilizes research-based behavior-reduction procedures.
2.07 Participating provider trains for and measures generalization throughout treatment.
2.08 Participating provider ensures skills are age-appropriate based on the developmental order in which skills are acquired in individuals with typical development.
2.09 Participating provider has resources available to service non-verbal/non-vocal children.
2.10 Participating provider collaborates with appropriately qualified professional to facilitate language acquisition.
2.11 A BHCOE determines treatment dosage (hours) based on professional judgment, research, and standard of care.
3.01 Participating provider notifies caregivers of expectations for involvement in programming.
3.02 Participating provider educates caregivers on clinical outcomes of parent involvement in their child’s progress.
3.03 Participating provider has standard requirements for caregiver participation and training independent of the patient’s funding source.
3.04 Participating provider makes reasonable efforts to involve caregivers in training, participation and treatment planning.
3.05 Participating provider appropriately documents caregiver participation or lack of participation in treatment sessions and planning.
3.06 Participating provider ensures eLearning opportunities are easily accessible to caregivers.
3.07 Participating provider makes reasonable efforts to collaborate with other professionals (e.g., speech-language pathologists, occupational therapists, school staff, physicians, etc.) to maximize clients’ progress.
3.08 Participating provider provides a clear policy to clients on collaboration with non-evidence-based practices.
4.0 Ethics & Consumer Protection
4.01 If participating provider holds a waitlist, they clearly communicate expectations of waitlist time to families.
4.02 Participating provider offers resources to potential clients if unable to initiate services within 45 days of contact.
4.03 Participating provider offers families with peer-referral options to potential clients if unable to provide services within 1 month of contact.
4.04 Participating provider maintains close supervision over wait list times and caregiver needs.
Marketing & Representation
4.05 Participating provider accurately represents the services they provide.
4.06 Participating provider does not engage in misleading, false, or deceptive statements.
4.07 Participating provider does not exploit consumers of their services for marketing purposes.
4.08 Participating provider uses testimonials in compliance with BACB® Professional and Ethical Compliance Code for Behavior Analysts.
Promoting Ethical Behavior
4.09 Participating provider obeys all applicable federal, state and local laws related to health, safety, and employment.
4.10 Participating provider supports any workers who come forward with any claim of undue pressure to violate the BHCOE® Code of Effective Behavior Organizations or BACB® Professional and Ethical Compliance Code for Behavior Analysts.
4.11 Participating provider appoints an internal Ethics Officer and/or Ethics Committee to address internal ethical issues.
4.12 Participating provider obtains any relevant consent from consumers of their services.
4.13 Prior to commencement of service delivery, provider informs consumer where they can file complaints about any service provided by their organization.
4.14 Prior to implementation of services, participating provider provides in writing, the terms of consultation, requirements for providing services, financial agreements, treatment expectations, duration of treatment, the likelihood of success,.and responsibilities of all parties. If terms change, behavioral organizations will notify consumers.
5.0 HIPAA Compliance
Client/patient confidentiality and privacy should be consistent with applicable federal regulations including the Health Insurance Portability and Accountability Act of 1996 and Title 42 of the Code of Federal Regulations, state laws, code(s) of conduct, and professional guidelines;
5.01 Participating provider has determined where PHI will be located.
5.02 Participating provider has appointed a HIPAA privacy/security official.
5.03 Participating provider has determined how or why PHI will be disclosed.
5.04 Participating provider uses HIPAA-compliant electronic communication.
5.05 Participating provider uses HIPAA-compliant cloud or server-based storage.
5.06 Participating provider has HIPAA breach policy.
5.07 Participating provider has a data backup plan.
5.08 Participating provider provides HIPAA compliance training to staff.
6.0 Caregiver Satisfaction
Participating provider operates in a manner that indicates caregiver satisfaction at 80% or higher.
7.0 Employee Satisfaction
Participating provider operates in a manner that indicates staff satisfaction at 80% or higher.