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Behavioral Health Center of Excellence
2020 BHCOE FULL ACCREDITATION SELF-EVALUATION CHECKLIST
Behavioral Health Center of Excellence ©2020 2020 BHCOE Full Accreditation Self-Evaluation Checklist | 2
CHECKLIST
A. General Requirements
Y N N/A
l l ll l l A.01 Organization is registered or incorporated.
l l ll l l A.02 Organization has general, property, and liability insurance.
l l ll l l A.03 Organization has a valid business license.
l l ll l l A.04 Organization has a payroll, accounting and record-keeping system and/or software.
l l ll l l A.05 Organization has workman’s compensation insurance.
l l ll l l A.06 Organization has a staff handbook.
l l ll l l A.07 Organization has a current working budget and proposed next year budget.
l l ll l l A.08 Organization has a defined organizational structure and hierarchy.
l l ll l l A.09 Organization has job descriptions and expectations for all current positions.
l l ll l l A.10 Organization has minimum qualifications and requirements for each job position.
B. Hiring
Y N N/A
l l ll l l B.01 Organization has an organization-specific employment application.
l l ll l l B.02 Organization has a templated offer letter.
l l ll l l B.03 Organization has a checklist for new hires.
l l ll l l B.04 Organization conducts state and federal background checks.
l l ll l l B.05 Organization has staff performance and evaluation guidelines.
l l ll l l B.06 Organization provides safety/crisis management training to staff who may encounter dangerous behavior.
l l ll l l B.07 Organization trains staff on mandated reporting requirements.
l l ll l l B.08 Organization checks all staff Motor Vehicle records.
C. HIPAA
Y N N/A
l l ll l l C.01 Organization has determined where PHI will be located.
l l ll l l C.02 Organization has an appointed HIPAA privacy/security official.
l l ll l l 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.).
l l ll l l C.04 Organization’s email and other electronic communication are HIPAA-compliant.
l l ll l l C.05 Organization’s cloud or server-based storage is HIPAA-compliant.
l l ll l l C.06 Organization has a HIPAA breach policy.
l l ll l l C.07 Organization has a data backup plan.
l l ll l l C.08 Organization has HIPAA compliance training.
D. Intake
Y N N/A
l l ll l l D.01 Organization has a patient intake form & questionnaire.
l l ll l l D.02 Organization has a patients’ rights agreement.
l l ll l l D.03 Organization provides a financial responsibility agreement to patients.
l l ll l l D.04 Organization has a confidential exchange of information policy.
l l ll l l D.05 Organization has a new patient welcome letter.
l l ll l l D.06 Organization has a written standard treatment or operating procedure for ABA services that is provided to new patients.
l l ll l l D.07 Organization has a patient home safety checklist.
l l ll l l D.08 Organization has an ABA treatment contract.
l l ll l l D.09 Organization has a parent/guardian interaction policy.
l l ll l l D.10 Organization has a patient illness policy.
l l ll l l D.11 Organization has a fee agreement and payment policy.
l l ll l l D.12 Organization has a new patient form and checklist.
l l ll l l D.13 Organization has a Notice of Privacy Practices
Use the following checklist to prepare for BHCOE Accreditation.
Behavioral Health Center of Excellence ©2020 2020 BHCOE Full Accreditation Self-Evaluation Checklist | 3
for patients.
E. Clinical
Y N N/A
l l ll l l E.01 Organization has an assessment report template.
l l ll l l E.02 Organization has a progress report template.
l l ll l l E.03 Organization has a supervisor case note template.
l l ll l l E.04 Organization has a paraprofessional/technician case note template.
l l ll l l E.05 Organization has a reinforcement assessment system for patients.
l l ll l l E.06 Organization has a data collection system.
l l ll l l E.07 Organization has a caregiver training protocol.
l l ll l l E.08 Organization utilizes a standardized assessment when evaluating patients.
l l ll l l E.09 Organization has a plan for how often they will conduct assessments.
l l ll l l E.10 Organization has a curriculum for developing patient programming.
l l ll l l E.11 Organization has a designated quality assurance officer.
l l ll l l E.12 Organization has guidelines for recommending treatment intensity of services.
l l ll l l E.13 Organization has a fade-out policy.
F. Consumer Protection
Y N N/A
l l ll l l F.01 Organization has a conflict of interest policy.
l l ll l l F.02 Organization has guidelines regarding the exchange of gifts, money, or personal fundraising.
l l ll l l F.03 Organization has guidelines for how the organization is represented via social media.
l l ll l l F.04 Organization protects patient privacy by refraining from posting patient information or photos on social media.
l l ll l l F.05 Organization refrains from soliciting and posting testimonials.
l l ll l l F.06 Organization has written ethical codes of conduct.
l l ll l l F.07 Organization has legal representation.
l l ll l l 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 patient or parent/guardian about how to choose effective services.
G. Liability
Y N N/A
l l ll l l G.01 Organization has cyber or data privacy insurance.
l l ll l l G.02 Organization has a fidelity bond in place.
l l ll l l G.03 Organization has abuse prevention policies and procedures.
l l ll l l G.04 Organization has a policy in place to avoid one-to-one situations with patients.
1.0 Staff Qualifications, Training & Oversight
Y N N/A
l l ll l l 1.01 Organization employs clinical director-level staff who hold adequate education and qualifications.
l l ll l l 1.02 Organization employs supervisory staff who hold adequate education and qualifications.
l l ll l l 1.03 Organization employs direct staff who hold adequate education and qualifications.
l l ll l l 1.04 Organization tests for clinical competence prior to staff providing treatment to patients.
l l ll l l 1.05 Organization 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 practices, etc.).
l l ll l l 1.06 Organization provides staff with continuing education in line with their areas of need.
l l ll l l 1.07 Organization ensures consistency of treatment across staff members through staff overlap, data collection, and/or team meetings.
Behavioral Health Center of Excellence ©2020 2020 BHCOE Full Accreditation Self-Evaluation Checklist | 4
l l ll l l 1.08 Organization will utilize staff performance evaluation processes such as goal-setting, performance measurement, regular performance feedback, and self-evaluation, as evidenced by documentation of staff progress.
l l ll l l 1.09 Organization defines organizational structure and hierarchy.
l l ll l l 1.10 Organization provides job descriptions and expectations for all current positions.
2.0 Treatment Program & Planning
Y N N/A
l l ll l l 2.01 Organization utilizes standardized assessments to evaluate patient outcome annually, or more frequently if needed.
l l ll l l 2.02 Organization collects and monitors individual outcome data.
l l ll l l 2.03 Organization collects and monitors organizational outcome data.
l l ll l l 2.04 Organization utilizes evidence-based curricula when developing patient goals.
l l ll l l 2.05 Organization utilizes research-based skill-acquisition procedures.
l l ll l l 2.06 Organization utilizes research-based behavior-reduction procedures.
l l ll l l 2.07 Organization trains for and measures generalization throughout treatment.
l l ll l l 2.08 Organization ensures skills are age-appropriate based on the developmental order in which skills are acquired in individuals with typical development.
l l ll l l 2.09 Organization has resources available to service non-verbal/non-vocal patients.
l l ll l l 2.10 Organization collaborates with appropriately qualified professionals to facilitate language acquisition.
l l ll l l 2.11 Organization determines treatment dosage based on professional judgment, research, and standard of care.
3.0 Collaboration & Coordination of Care
Y N N/A
l l ll l l 3.01 Organization notifies parent/guardian of expectations for involvement in programming.
l l ll l l 3.02 Organization educates parent/guardian on clinical outcomes of their involvement in the patient’s progress.
l l ll l l 3.03 Organization has standard requirements for parent/guardian participation and training independent of the patient’s funding source.
l l ll l l 3.04 Organization makes reasonable efforts to involve parent/guardian in training, participation and treatment planning.
l l ll l l 3.05 Organization appropriately documents parent/guardian participation or lack of participation in treatment sessions and planning.
l l ll l l 3.06 Organization ensures eLearning opportunities are easily accessible to parents/guardians.
l l ll l l 3.07 Organization makes reasonable efforts to collaborate with other professionals (e.g., speech-language pathologists, occupational therapists, school staff, physicians, etc.) to maximize a patient’s progress.
l l ll l l 3.08 Organization provides a clear policy to patients or parent/guardian on collaboration with non-evidence-based practices.
4.0 Ethics & Consumer Protection Y N N/A Waitlist
l l ll l l 4.01 If the organization holds a waitlist, they clearly communicate expectations of waitlist time to patient or parent/guardian.
l l ll l l 4.02 Organization offers resources to potential patient or parent/guardian if unable to initiate services within 45 days of contact.
l l ll l l 4.03 Organization offers patient or parent/guardian with peer-referral options to potential patients if unable to provide services within 1 month of contact.
l l ll l l 4.04 Organization maintains close supervision over wait list times and patient or parent/guardian
Behavioral Health Center of Excellence ©2020 2020 BHCOE Full Accreditation Self-Evaluation Checklist | 5
needs.
Y N N/A Marketing & Representation
l l ll l l 4.05 Organization accurately represents the services they provide.
l l ll l l 4.06 Organization does not engage in misleading, false, or deceptive statements.
l l ll l l 4.07 Organization does not exploit consumers of their services for marketing purposes.
l l ll l l 4.08 Organization uses testimonials in compliance with BACB® Professional and Ethical Compliance Code for Behavior Analysts. Promoting Ethical Behavior
l l ll l l 4.09 Organization 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.
l l ll l l 4.10 Organization appoints an internal ethics officer and/or ethics committee to address internal ethical issues.
l l ll l l 4.11 Organization obtains any relevant consent from patient or parent/guardian of their services.
l l ll l l 4.12 Prior to the commencement of service delivery, the organization informs patient or parent/guardian where they can file complaints about any service provided by their organization.
l l ll l l 4.13 Prior to implementation of services, the organization 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 patient or parent/guardian.
5.0 HIPAA Compliance 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;
Y N N/A
l l ll l l 5.01 Organization has determined where PHI will be located.
l l ll l l 5.02 Organization has appointed a HIPAA privacy/security official.
l l ll l l 5.03 Organization has determined how or why PHI will be disclosed.
l l ll l l 5.04 Organization uses HIPAA-compliant electronic communication.
l l ll l l 5.05 Organization uses HIPAA-compliant cloud or server-based storage.
l l ll l l 5.06 Organization has HIPAA breach policy.
l l ll l l 5.07 Organization has a data backup plan.
l l ll l l 5.08 Organization provides HIPAA compliance training to staff.
6.0 Patient Satisfaction The organization operates in a manner that indicates patient or parent/guardian satisfaction at 80% or higher.
7.0 Employee Satisfaction The organization operates in a manner that indicates staff satisfaction at 80% or higher.
Tally your score. _ Total your number of “Yes” responses and compare
your score with the chart on the following page.
Behavioral Health Center of Excellence ©2020 2020 BHCOE Full Accreditation Self-Evaluation Checklist | 6
89* Work in Progress
90-94 Almost a BHCOE
95-99 Likely a BHCOE
100-106 BHCOE
Behavioral Health Center of Excellence 7083 Hollywood Boulevard #565, Los Angeles, CA 90028
Telephone 310-627-2746 www.bhcoe.org
*Please note that the scores do not include your patient or staff's satisfaction forms.
