Behavioral Health Center of Excellence®

BHCOE ®

ACCREDITATION
STANDARDS
2022 2021
CROSSWALK
BHCOE Accreditation Standards
2022 2021 Crosswalk

A. Ethics Integrity & Professionalism

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A.01 SAME
The organization acts in the best interest of the patients it serves
at all times.

A.02 SAME
The organization, and its subsidiaries are in compliance with all
applicable healthcare regulatory and licensing laws.

A.03 SAME
The organization, subsidiary, or any of its owners, officers, and
directors are not currently and have not been convicted of, charged,
under an investigation, or subject to any enforcement action or legal
proceeding by any governmental authority arising out of or relating
to any healthcare regulatory law within the past year.

A.04 SAME
The organization acts honestly and responsibly to promote ethical
practices of its staff and supports certified staff in complying
with ethical and professional requirements of their certifying and/
or licensing body. The organization never directs staff to act in
violation of those requirements, instead resolving any conflicts
between the company policy and those requirements.

A.05 SAME
The organization is dedicated to ethical and fair competition and
will not improperly coordinate to sabotage, speak ill of,
or undermine other ABA service organizations.

A.06 SAME
The organization ensures staff avoid dual relationships that might
impair the ability to make objective and fair decisions.

A.07 SAME
The organization protects the privacy of its workers.

A.08 SAME
The organization does not offer incentives or remuneration to
current patients in exchange for attendance or recruitment of
other patients. Remuneration refers to cash, cash-equivalents,
or anything of value.

A.09
The organization provides staff a confidential means to
report suspected misconduct, unethical behavior, or other
grievances and has a process for addressing such reports.
The organization has a policy prohibiting retaliation against
persons reporting misconduct.
A.09
The organization provides employees, patients, and volunteers
a confidential means to report suspected impropriety or misuse
of organizational resources. The organization has a policy
prohibiting retaliation against persons reporting improprieties.

A.10 SAME
The organization has a designated ethics officer or ethics
committee to address ethical issues such as patient programming
and organizational, staff, and patient concerns.

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B. Diversity

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B.01 B.01
The organization has a diversity statement that clearly expresses The organization has a diversity statement.
its ongoing commitment to an iterative process of developing
an inclusive and equitable organizational culture, protecting
and supporting staff, protecting and supporting patients, and
devising steps the organization will take to ensure diversity,
equity, and inclusion.

B.02
The organization is committed to and has a process for
evaluating marketing, training, and therapeutic materials
that ensure representation of diverse individuals, including
(at a minimum) individuals with diverse age, gender, race and
ethnicity, language, economic conditions, religion, and disability.
B.03
The organization has representation of diverse individuals at a
minimum including age, gender, race/ethnicity, and disability.
Instructional, training, and marketing materials include diverse
images and narratives.

B.03 B.08
The organization engages in qualitative and/or quantitative The organization engages in self-assessment of diversity efforts
self-assessment of diversity efforts including diversity of at least annually.
vendors and suppliers at least annually.

B.04 B.06
The organization is committed to and has a process for evaluating The organization actively recruits and engages in retention
talent acquisition efforts to ensure a diverse candidate slate. strategies to promote a diverse workforce.

B.05 B.07
The organization engages in fair hiring and employment practices. The organization demonstrates engagement in fair hiring
practices, as regulated by Equal Employment Opportunity
Commission (EEOC).

B.06 B.05
The organization provides cultural humility training and
competency checks to all staff upon hire, annually, and as
required by state and federal guidelines.

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B. Diversity (Cont’d.)

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B.07
The organization ensures that leadership and supervisory staff
have completed conflict resolution training that addresses
responding to bias incidents and has an objective, neutral
process for responding to bias incidents.
B.11
The organization assures that leadership have completed
conflict resolution training and has process(s) for responding
to bias incidents.

B.08
The organization has access to and when necessary, utilizes
translation services for oral and written communication and
communicates availability of translation services to patients in
line with state and federal laws and regulations.
B.02
The organization has access to and when necessary, utilizes
translation services for oral and written communication and
communicates availability of translation services to patients.

B.09 SAME
The organization’s physical location is compliant with the
Americans with Disabilities Act.

B.10 B.04
The organization makes closed captioning available on all The organization makes closed captioning available for its videos.
video content. This item is not applicable for organizations that do not have
video content.

B.11 B.10
The organization makes a good faith effort to provide services to The organization has a means to and actively allows qualified low-
qualified underserved patients. income patients access to services.

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C. General Requirements & Liability

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C.01 SAME
The organization has processes in place to ensure it maintains
state and local requirements regarding business registration,
incorporation, and licensing.

C.02 SAME
The organization sufficiently protects against claims resulting
from injuries or damages by maintaining general, property, and
liability insurance.

C.03 SAME
The organization obtains workers’ compensation insurance.

C.04 SAME
The organization has protections to ensure the organization, its
staff and patients are protected from a cyber-related incident by
obtaining cyber or data privacy insurance.

C.05
The organization monitors resource allocation, planning,
and coordination by monitoring accuracy of payroll as well
as current and future business income and expenditures via a
working budget.
C.05
The organization has process and systems in place to assure
accuracy of payroll calculations, deductions, and expenses.
C.07
The organization develops a budget to forecast expenditures,
income, and profitability.

C.06 C.06
The organization implements an operational or strategic plan to The organization develops a strategic plan to account for growth
account for growth and/or improvement and adherence to the and/or improvement, at least annually.
annual budget, at least annually.

C.07 C.08
The organization maintains an ongoing relationship with
legal representation.

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D. Recruiting, Hiring & Retention

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D.01 SAME
The organization uses qualifying questions to screen
candidates, standard interview questions, and acceptance
criterion for each position.

D.02 SAME
The organization has an organization-specific employment
application and offer letter.

D.03 D.07
The organization has job descriptions for each position
with minimum qualifications, lines of reporting, hierarchy,
and job duties.

D.04 D.06
The organization does not engage in hiring practices that could
restrict non-executive clinical staff’s future employment, such
as by requiring non-executive clinical staff to sign non-compete
agreements. This does not preclude an organization from relying
on non-solicitation and non-disclosure agreements.

D.05 D.04
The organization conducts state and federal background The organization conducts state and federal background checks
checks on all staff before they provide work or services on the on all employees prior to hire.
organization's behalf.

D.06 D.03
The organization has administrative and clinical onboarding
checklists for new hires.

D.07 D.08
The organization utilizes a staff handbook. The organization utilizes an employee handbook in line with
state-specific labor laws.

D.08 D.05
The organization has a patient transportation policy that is The organization verifies all employees hold a valid driver’s
provided to staff prior to transporting patients and outlines the license, motor insurance, and clean motor vehicle record for
requirements for staff transporting patients including licensing those employees who transport patients.
requirements, insurance requirements, motor vehicle record
requirements, and other regulatory requirements related to
patient transportation.

D.09 D.17
Organization has a plan to ensure it is prepared for senior
leadership changes.

D.10 D.16
The organization regularly measures employee The organization regularly measures employee satisfaction
satisfaction and has processes for responding to and makes reasonable efforts to resolve employee concerns
results of satisfaction measurement. or grievances.

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D. Recruiting, Hiring & Retention (Cont’d.)

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D.11 NEW
The organization conducts assessments of leadership
effectiveness and shares how they utilize results of the
assessment to improve.

D.12 NEW
The organization conducts ongoing assessment of employee
voluntary turnover and makes effort to minimize turnover that
may be due to organizational factors.

D.13 D.09
The organization retains clinical director staff who holds a
master's or doctoral level certification/license in behavior analysis
and/or related field and has at least 3 years supervising cases or
equivalent experience.

D.14 D.10
The organization employs supervisors who hold a graduate-
level certification in good standing in Applied Behavior Analysis
from a nationally accredited certifying body, meet the certifying
body's current standards for supervision, and hold a graduate
degree. When applicable, supervisors should also be licensed in
their state. An organization may apply for a staff exception on an
individual basis.

D.15 D.11
The organization employs direct care staff who hold at least a
high school diploma, GED certificate, or a degree from post-
secondary institution and are required to obtain certification
or licensure as applicable, within 6 months, or are certified/
licensed as a direct care staff by an accredited certifying body.
Organization may apply for a staff exception on an individual
basis.

D.16 D.12
The organization provides training in clinical and administrative
tasks for each level of staff upon hire.

D.17 I.07
The organization provides safety and crisis management training
for employees.

D.18
The organization has documented policies and procedures on
mandated reporting requirements and conducts training on
these requirements annually or more frequently as mandated by
state requirements.
I.08
The organization has an employee policy and procedure
on mandated reporting requirements including a policy,
documented training, and procedure.

D.19 D.13
The organization evaluates and assures the competence of staff
prior to allowing them to provide treatment to patients.

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D. Recruiting, Hiring & Retention (Cont’d.)
2022 BHCOE
Accreditation Standards
D.20
The organization supports continuing education and credential
maintenance needs of staff in line with their certification.
D.21
The organization provides enhanced education opportunities to
staff appropriate to their specific areas of need.
D.22
The organization has a process for providing ongoing
performance feedback and appropriate consequences
as needed.
D.23
The organization utilizes formal feedback processes for
performance review that cover clinical and administrative
skills and include appropriate consequences for each level
of personnel.
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Accreditation Standards
D.14
The organization ensures employees at every level receive
continuing education, training, and oversight in line with their
certification and specific areas of need.
D.14
The organization ensures employees at every level receive
continuing education, training, and oversight in line with their
certification and specific areas of need.
D.15
The organization utilizes employee performance evaluation
processes such as goal setting, performance measurement,
regular performance feedback, self-evaluation, and appropriate
corrective or positive consequences for each level of employees.
D.15
The organization utilizes employee performance evaluation
processes such as goal setting, performance measurement,
regular performance feedback, self-evaluation, and appropriate
corrective or positive consequences for each level of employees.
BHCOE Accreditation Standards
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E. Patient Intake

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E.01 E.10
The organization recognizes, in its policies, procedures, and
business practices, that the direct recipient of services is its
primary patient, along with the parent or guardian of the direct
recipient of services, even if a third party is paying for the
services. The organization resolves any conflicts in the best
interests of the direct recipient of services.

E.02 E.01
The organization clearly communicates how patients can initiate
services with the organization to ensure patients have equal
access to services.

E.03 E.02
The organization has a standard operating procedure for
ensuring timely and efficient onboarding of new patients.

E.04 E.08
The organization collects and monitors data on latency from The organization collects and monitors data on waitlist length
point of first contact to assessment and from assessment to and estimated waitlist time.
initiation of treatment.

E.05 E.09
When an organization places a patient on a waitlist, the
organization notifies them of the estimated wait time, shares
resources about the value of timely access to treatment, and
provides suggestions on how to access care in a timely manner.

E.06 E.03
The organization has a process in place to facilitate the
verification of benefits in a timely manner, when applicable.

E.07 E.06
Prior to the initiation of services, the organization provides,
in writing, requirements for providing services, patient rights,
financial agreements, and responsibilities of all parties. If terms
change, the organization will notify parents/guardians and/or
patients in advance of the new terms taking effect.

E.08 NEW
Prior to the initiation of services (including assessment), the
organization educates the patient about the risks and benefits of
treatment and obtains informed consent from the patient and/or
parent/guardian/caregiver.

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E. Patient Intake (Cont’d.)

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E.09 E.04
The organization seeks initial authorization from payor before
providing assessment or other services, when applicable.

E.10 E.05
The organization regularly monitors credentialing requirements,
contract, and authorization expiration date for each payor.

E.11 E.07
The organization makes reasonable efforts to fulfill all therapy
hours recommended within the patient’s clinical assessment.

E.12
The organization has a policy that outlines discharge plans
and processes to ensure an equitable process for discharging
patients, including written notice to relevant parties, a clear
timeline for transition from the current level of care, and a plan
to address any urgent patient needs. The organization makes
patients aware of the policy at the onset of services.
E.11
Organizations act in the best interests of the patient, including
the direct recipient of services and their parent/guardian to avoid
interruption or disruption of service. The organization does not
terminate services without a 30-day notice, and without efforts to
transition, unless the patients’ needs require prompt termination.

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F. Service Delivery

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F.01 F.05
The organization has a process that guides skill acquisition The organization exclusively utilizes evidence-based
programming that 1) are conceptually systematic with applied clinical practices.
behavior analysis, 2) are informed by the best available
contemporary research, 3) are selected and/or adapted to reflect
client values, 4) are commensurate with the clinical expertise of
the professionals responsible for overseeing and implementing
those practices and, 5) incorporate evidence-based decision
making in evaluating and revising clinical practices.

F.02 F.05
The organization has a process that guides behavior reduction The organization exclusively utilizes evidence-based
programming that 1) are conceptually systematic with applied clinical practices.
behavior analysis, 2) are informed by the best available
contemporary research, 3) are selected and/or adapted to reflect
client values, 4) are commensurate with the clinical expertise of
the professionals responsible for overseeing and implementing
those practices and, 5) incorporate evidence-based decision
making in evaluating and revising clinical practices.

F.03 F.01
The organization uses evidence-based and developmentally
appropriate assessments to evaluate patient outcomes annually,
or more frequently if needed.

F.04 F.07
The organization ensures goals are appropriate based on current
developmental level, chronological age, and the developmental
order in which skills are acquired in individuals with typical
development.

F.05 F.08
The organization provides treatment recommendations by
relying on best practices such as decision models, research,
and professional judgment. Treatment recommendations may
include hours, amount of supervision, setting, approach, or
frequency of treatment.

F.06 F.02
The organization has a process for prescribing data collection The organization collects and monitors individual patient
and analysis procedures including the types of data to be outcome data.
collected, the method of data collection, the frequency of data
collection, procedures for ensuring reliability of data collection, G.07
and frequency of data analysis.
The organization collects daily data related to patient progress.

F.07 F.11
The organization ensures intervention is delivered with treatment
fidelity as written in the treatment plan. The organization ensures
that implementation of services adheres to prescribed protocols.

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F. Service Delivery (Cont’d)

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F.08 G.06
The organization utilizes preference assessment procedures The organization has a preference assessment policy
to generate an environment conducive to learning and and procedure.
accommodate patient motivation.

F.09 F.06
The organization trains for and measures generalization and
maintenance throughout treatment.

F.10 NEW
The organization provides patients of all abilities with a
collaborative process to enable them to provide meaningful input
in the selection of treatment goals and interventions.

F.11 F.09
The organization ensures clinicians carry a caseload that enables
them to provide appropriate supervision and oversight to
facilitate effective treatment.

F.12 F.03
The organization collects and monitors clinical outcomes across
all patients.

F.13 F.10
The organization regularly measures patient satisfaction and has The organization regularly measures patient satisfaction
processes for responding to results of satisfaction measurement. and makes reasonable efforts to resolve patient concerns or
grievances.

F.14 F.04
The organization has a quality assurance officer.

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G. Clinical Documentation

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G.01 G.02
The organization has a standard clinical assessment report The organization has a standard clinical assessment
template that meets at a minimum BHCOE Standard 101: report template.
Documentation of Clinical Records for Applied Behavior
Analysis Services.

G.02 G.03
The organization has a standard progress report and/or The organization has a standard progress report or
treatment plan template that meets at a minimum BHCOE treatment plan template.
Standard 101: Documentation of Clinical Records for Applied
Behavior Analysis Services.

G.03 NEW
The organization has a standard discharge summary template.

G.04 G.04
The organization has a standard template for documenting the The organization has a standard supervisor case note template.
session activities of qualified health care professionals (e.g.,
direct therapy, assessment activity, progress reporting, case
supervision) that meets at a minimum BHCOE Standard 101:
Documentation of Clinical Records for Applied Behavior Analysis
Services.

G.05 G.05
The organization has a standard template for documenting the The organization has a standard mid-level and/or direct care
activities of those delivering direct ABA services to patients that employee case note template.
meets at a minimum BHCOE Standard 101: Documentation of
Clinical Records for Applied Behavior Analysis Services.

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H. Collaboration & Coordination of Care
2022 BHCOE
Accreditation Standards
H.01
Before the commencement of service delivery, the organization
informs parents/guardians and/or patients how they can file
complaints and grievances internally and externally about any
service provided by the organization and with BHCOE once the
organization is accredited. The organization prohibits retaliation
against individuals reporting concerns or complaints.
H.02
The organization educates parents/guardians of patients on the
therapeutic impact of their involvement, and shares information
about evidence-based decision making.
H.03
The organization makes reasonable efforts to involve parents,
guardians and/or caregivers of patients in care planning and does
not make significant changes to treatment plans without consent.
H.04
The organization maintains standard expectations for frequency
of parent/guardian/caregiver involvement and training, and has
a process for conducting assessments for patients who may be
exempted from standard requirements.
H.05
The organization appropriately documents parent/guardian/
caregiver involvement in treatment, including reporting on
caregiver goals (when appropriate) and barriers to parent/
guardian/caregiver involvement.
H.06
The organization makes reasonable efforts to collaborate with
other professionals on a treatment team such as occupational
therapists, school staff, speech-language pathologists, and/or
physicians to maximize the patient’s progress.
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Accreditation Standards
H.01
Before the commencement of service delivery, the organization
informs the caregiver and/or patients how they can file
complaints and grievances internally and externally about any
service provided by the organization and with BHCOE once the
organization is accredited.
H.02
The 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 patients about how to choose
effective services.
H.03
The organization educates parents/guardians of patients on the
therapeutic impact of their involvement.
H.04
H.05
The organization establishes minimum parents/guardians
participation/training goals regardless of funding source.
H.06
The organization makes reasonable efforts to involve parents/
guardians in the treatment implementation process.
H.07
The organization appropriately documents parents/guardians’
participation or lack thereof in treatment sessions and planning.
H.08
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I. Health, Safety & Emergency Preparedness

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I.01 I.01
The organization has a system in place to protect clients from The organization has a policy to protect against abuse or
abuse which includes a policy to protect against abuse that is allegations of abuse.
disseminated to staff and patients, abuse prevention training for
all staff (at hire and at least annually thereafter), and procedures
for reporting and addressing allegations of abuse.

I.02 I.11
The organization has a policy in place to ensure a planned or ad-
hoc review occurs as a response to injuries and safety incidents.

I.03 SAME
The organization provides access to first aid kit supplies to
staff and/or has a first aid kit available in all locations where
therapeutic activities take place.

I.04 I.05
The organization has a documented plan and conducts trainings The organization has guidelines for safe medication
for safe medication management, in accordance with state and management, if applicable.
federal requirements, when applicable.

I.05 I.09
The organization has a patient illness policy and procedure.

I.06 I.10
The organization has a patient safety checklist that addresses
location specific and patient specific safety considerations.

I.07 I.02
The organization conducts and documents fire drills at least The organization conducts and documents fire drills
quarterly or more frequently as mandated by state and at least annually.
local requirements.

I.08 I.06
The organization conducts an assessment to identify the disaster The organization has a written emergency plan for disaster
preparedness needs of their geographical region, environment, and casualties.
and service recipients, has a documented plan, conducts
trainings, and has necessary supplies to address those needs.

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J. Media, Communication & Representation
2022 BHCOE
Accreditation Standards
J.01
The organization accurately represents the services it provides to
patients, staff, and/or other stakeholders and does not engage in
misleading, false, or deceptive statements.
J.02
The organization has guidelines for how the organization is
represented in social media.
J.03
When soliciting client participation in marketing activities the
organization 1) does not permit staff to solicit current patients
and 2) the organization uses an open casting call approach.
J.04
If an organization engages in marketing activities, the
organization does not conduct such activities in a manner that
interferes with regularly scheduled treatment services and does
not compromise quality of care.
J.05
The organization has documented systems for obtaining written
patient consent for use of photos, videos, and testimonial/
commentary, including for marketing, training, instruction, or
other uses. Systems include ensuring consent clearly describes
the permissions given, has an expiration date, is renewed
annually, notifies patients that they can rescind consent at any
time without penalty, notifies patients how to rescind consent
and fulfilling requests to rescind consent.
J.06
The organization does not permit staff to share or create media
likely to result in the sharing of any identifying information
(written, photographic, or video) about current or past patients
and supervisees within social media contexts.
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Accreditation Standards
J.01
The organization accurately represents the services it provides to
patients, employees, and/or other stakeholders.
J.02
The organization does not engage in misleading, false, or
deceptive statements to patients, employees, and/or other
stakeholders.
J.03
J.04
The organization does not permit clinical employees to solicit
or use testimonials about behavior-analytic services from
current patients on their webpages or in any other electronic
or print material
J.06
If an organization utilizes current or past patients to share stories,
the organization does not solicit individual patients but, rather,
uses an open casting call approach, or use stories provided
unsolicited by patients.
J.07
If an organization utilizes current or past patients to share stories,
the organization does not conduct such activities during regularly
scheduled treatment hours.
J.09
The organization provides opportunities for patient video or
photo releases to be renewed annually and provides clear
instructions regarding how to revoke consent, if requested.
J.05
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K. HIPAA/Compliance
2022 BHCOE
Accreditation Standards
K.01
The organization ensures that patients are aware of their rights
and organizational practices concerning the security and
availability of their personal information related to all facets of
service delivery.
K.02
The organization has systems, policies, and procedures for the
implementation of security measures to protect and maintain the
continuity of individual patients’ information related to all facets
of service delivery when that information is in use, in transit, and
being stored. Security measures must be applied to electronic
and physical information.
K.03
The organization has processes in place, such as training, oversight
and feedback, and contractual agreements, to assure that those
providing work on their behalf, including staff, contractors,
and vendors, implement security measures to protect patient
information related to all facets of service delivery.
K.04
The organization has systems, policies, and procedures in place
for responding to breaches or potential breaches in the security
of all forms of individual patients’ information related to all facets
of service delivery.
K.05
The organization has systems in place and a person designated
to ensure compliance with internal policies and procedures as
well as external regulatory and contractual requirements.
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Accreditation Standards
K.01
The organization, prior to the implementation of services, informs
parents/guardians in writing a notice of privacy practices.
K.02
The organization uses HIPAA-compliant electronic
communication that includes a confidentiality disclaimer.
K.03
The organization uses HIPAA-compliant cloud or server-based
storage. K.06 The organization limits access to Protected Health
Information (PHI) only to personnel who require such access in
the course of their job duties.
K.07
The organization utilizes a policy and procedure for the
protection of facilities and equipment storing PHI.
K.08
The organization has determined where PHI will be located and
how long it will be maintained.
K.10
The organization has a data backup policy and procedure.
K.05
The organization provides HIPAA compliance training to
employees upon hire, annually and as required otherwise.
K.04
The organization utilizes a HIPAA breach policy and procedure.
NEW