BHCOE Accreditation Standards

BHCOE’s Accreditation Standards include 11 sections relevant to the clinical, professional and ethical behaviors, processes, and systems of organizations providing Applied Behavior Analysis services, along with suggested evidence of compliance.

The 2021 standards became effective January 1, 2021, for all BHCOE-Accredited organizations.  All organizations, even those evaluated under the 2020 standards, are expected to be in compliance with the 2021 Standards. The 2022 standards went into effect on July 1, 2022. BHCOE’s expectation is that organizations accredited prior to July 2022 work toward compliance with the 2022 standards beginning July 1, 2022, and will be reassessed against those standards at their next evaluation cycle. 

BHCOE has established a compliance, disciplinary review and appeal process for matters of noncompliance with the Standards of Excellence that gives equal consideration to both the complainant and the accredited organization. The goal of the compliance process is to support the organization in establishing compliance, when possible. For the purpose of addressing alleged violations of the BHCOE Standards of Excellence, organizations will be held to the 2021 Standards of Excellence until they have been accredited under the 2022 Standards of Excellence. For more information regarding our compliance complaint process or to file a complaint against a BHCOE accredited organization please visit our Report a Compliance Concern page.

Looking for BHCOE’s current standard development activities and public commentary guidelines? Find them here.

Looking for BHCOE’s previous standards? Access them here.

 

Select the toggles below to read our standards for each type of accreditation:

2022 Full Accreditation Standards

A. Ethics, Integrity, & Professionalism

A.01 The organization acts in the best interest of the patients they serve at all times.

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

A.03** 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** 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 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** The organization ensures staff avoid dual relationships that might impair the ability to make objective and fair decisions.

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

A.08** 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.10* The organization has a designated ethics officer or ethics committee to address ethical issues such as patient programming and organizational, staff, and patient concerns.

B. Diversity, Equity, & Inclusion

B.01 The organization has a diversity statement that clearly expresses 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 engages in qualitative and/or quantitative self-assessment of diversity efforts including diversity of vendors and suppliers at least annually.

B.04* The organization is committed to and has a process for evaluating talent acquisition efforts to ensure a diverse candidate slate.

B.05 The organization engages in fair hiring and employment practices.

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

B.07 The organization ensures that leadership and supervisory staff have completed conflict resolution training that provides an objective, neutral process 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.09 The organization’s physical location is compliant with the Americans with Disabilities Act.

B.10* The organization makes closed captioning available on all video content.

B.11* The organization makes a good faith effort to provide services to qualified underserved patients.

C. General Requirements & Liability

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

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

C.03 The organization obtains workers’ compensation insurance.

C.04* 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.06 The organization implements an operational or strategic plan to account for growth and/or improvement and adherence to the annual budget, at least annually.

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

D. Hiring, Training, & Retention

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

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

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

D.04 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 The organization conducts state and federal background checks on all staff before they provide work or services on the organization’s behalf.

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

D.07 The organization utilizes a staff handbook.

D.08 The organization has a patient transportation policy that is provided to staff prior to transporting patients and outlines the requirements for staff transporting patients including licensing requirements, insurance requirements, motor vehicle record requirements, and other regulatory requirements related to patient transportation.

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

D.10* The organization regularly measures employee satisfaction and has processes for responding to results of satisfaction measurement.

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

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

D.13 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 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 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 The organization provides training in clinical and administrative tasks for each level of staff upon hire.

D.17 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.

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

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.

E. Patient Intake

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

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

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

E.05 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 The organization has a process in place to facilitate the verification of benefits in a timely manner, when applicable.

E.07 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 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.

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

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

E.11 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.

F. Service Delivery

F.01** The organization has a process that guides skill acquisition programming that 1) are conceptually systematic with applied 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** The organization has a process that guides behavior reduction programming that 1) are conceptually systematic with applied 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 The organization uses evidence-based and developmentally appropriate assessments to evaluate patient outcomes annually, or more frequently if needed.

F.04 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 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** The organization has a process for prescribing data collection and analysis procedures including the types of data to be collected, the method of data collection, the frequency of data collection, procedures for ensuring reliability of data collection, and frequency of data analysis.

F.07 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.

F.08 The organization utilizes preference assessment procedures to generate an environment conducive to learning and accommodate patient motivation.

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

F.10 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** The organization ensures clinicians carry a caseload that enables them to provide appropriate supervision and oversight to facilitate effective treatment.

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

F.13* The organization regularly measures patient satisfaction and has processes for responding to results of satisfaction measurement.

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

G. Clinical Documentation

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

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

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

G.04 The organization has a standard template for documenting the 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 The organization has a standard template for documenting the activities of those delivering direct ABA services to patients that meets at a minimum BHCOE Standard 101: Documentation of Clinical Records for Applied Behavior Analysis Services.

H. Collaboration & Coordination of Care

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.

I. Health, Safety, & Emergency Preparedness

I.01 The organization has a system in place to protect clients from abuse which includes a policy to protect against abuse that is 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 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 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 The organization has a documented plan and conducts trainings for safe medication management, in accordance with state and federal requirements, when applicable.

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

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

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

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

J. Media, Communication & Representation

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.

K. Security, Privacy, & Compliance

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.

Note:
*These items are not applied to evaluations for organizations that serve fewer than 25 patients.

** These items indicate Must Pass Standards. Evidence of having met these standards must be demonstrated during the evaluation in order to earn accreditation.

2022 Training Site Accreditation Standards

A. Ethics, Integrity, & Professionalism

A.01** The organization acts in the best interest of the patients it serves at all times. (Aligns with ABAI, BACB®, VCS)

A.04** 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 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. (Aligns with ABAI, BACB®, VCS)

A.06*, ** The organization ensures staff avoid dual relationships that might impair the ability to make objective and fair decisions. (Aligns with ABAI, BACB®, VCS)

A.07*, ** The organization protects the privacy of its workers. (Aligns with BACB®, VCS)

A.10 The organization has a designated ethics officer or ethics committee to address ethical issues such as patient programming and organizational, staff, and patient concerns. (Aligns with ABAI, BACB®)

B. Diversity, Equity, & Inclusion

B.01 The organization has a diversity statement that clearly expresses 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 (Aligns with ABAI, BACB®, VCS)

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, and disability. (Aligns with ABAI, VCS)

B.06 The organization provides cultural humility training and competency checks to all trainees and experience supervisors upon acceptance, annually, and as required by state and federal guidelines. (Aligns with ABAI, BACB®, VCS)

B.07 The organization ensures that leadership and supervisory staff have completed conflict resolution training that provides an objective, neutral process for responding to bias incidents. (Aligns with ABAI, BACB®)

C. General Requirements & Liability

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

D. Hiring, Training, & Retention

D.01 The organization uses qualifying questions to screen candidates, standard interview questions, and acceptance criterion for each position. (Aligns with ABAI)

D.05* The organization conducts state and federal background checks on all staff before they provide work or services on the organization’s behalf (Aligns with BACB®)

D.06* The organization has administrative and clinical onboarding checklists for new trainees and experience supervisors.

D.10 The organization regularly measures staff satisfaction and makes reasonable efforts to resolve staff concerns and grievances. (Aligns with ABAI, BACB®, VCS)

D.16* The organization provides training in clinical and administrative tasks for each trainee and experience supervisor upon acceptance.

D.17 The organization provides safety and crisis management training for trainees and experience supervisors. (Aligns with ABAI, BACB®, VCS)

D.18 ** The organization has documented policies and procedures on mandated reporting requirements and conducts training on these requirements annually or more frequently as stipulated by state requirements. (Aligns with BACB®, VCS)

D.19 The organization evaluates and assures the competence of trainees and experience supervisors prior to allowing them to provide treatment to patients. (Aligns with ABAI, BACB®)

D.20 The organization supports continuing education and credential maintenance needs of staff in line with their certification (Aligns with ABAI, BACB®)

D.21 The organization provides enhanced education opportunities to staff appropriate to their specific areas of need (Aligns with ABAI)

D.22 The organization has a process for providing ongoing performance feedback and appropriate consequences as needed. (Aligns with ABAI, BACB®, VCS)

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.(Aligns with ABAI, BACB®, VCS)

E. Patient Intake

E.07 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. (Aligns with BACB®)

E.08* 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. (Aligns with BACB®)

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. (Aligns with ABAI, BACB®, VCS)

F. Service Delivery

F.01** The organization has a process that guides skill acquisition programming that (1) are conceptually systematic with applied 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. (Aligns with ABAI, BACB®, VCS)

F.02** The organization has a process that guides behavior reduction programming that (1) are conceptually systematic with applied 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. (Aligns with ABAI, BACB®)

F.03 The organization uses evidenced-based and developmentally appropriate assessments to evaluate patient needs prior to implementing recommendations. (Aligns with ABAI, BACB®, VCS)

F.04 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. (Aligns with BACB®)

F.05 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. (Aligns with ABAI, BACB®)

F.06** The organization has a process for prescribing data collection and analysis procedures including the types of data to be collected, the method of data collection, the frequency of data collection, procedures for ensuring reliability of data collection, and frequency of data analysis. (Aligns with ABAI, BACB®, VCS)

F.07 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. (Aligns with ABAI, BACB®, VCS)

F.08 The organization utilizes preference assessment procedures to generate an environment conducive to learning and accommodate patient motivation.

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

F.10 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. (Aligns with ABAI, BACB®)

G. Clinical Documentation

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

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

G.03 The organization has a standard discharge summary template. (Aligns with ABAI)

G.04 The organization has a standard template for documenting the 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. (Aligns with ABAI)

G.05 The organization has a standard template for documenting the activities of those delivering direct ABA services to patients that meets at a minimum BHCOE Standard 101: Documentation of Clinical Records for Applied Behavior Analysis Services. (Aligns with ABAI)

H. Collaboration & Coordination of Care

H.02 The organization educates parents and guardians of patients on the therapeutic impact of their involvement and shares information about evidence- based decision-making (Aligns with BACB®, VCS)

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. (Aligns with ABAI, BACB®, VCS)

H.06 The organization makes reasonable efforts to collaborate with other professionals on a treatment team, such as occupational therapists, school personnel, speech-language pathologists, and physicians, to maximize the patient’s progress. (Aligns with ABAI, BACB®, VCS)

I. Health, Safety, & Emergency Preparedness

I.01 The organization has a system in place to protect clients from abuse which includes a policy to protect against abuse that is 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.03 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.06 The organization has a patient safety checklist that addresses location specific and patient specific safety considerations.

J. Media, Communication, & Representation

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. (Aligns with BACB®)

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. (Aligns with BACB®)

K. Security, Privacy, & Compliance

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. (Aligns with BACB®)

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 (Aligns with BACB®)

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. (Aligns with BACB®)

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. (Aligns with BACB®)

L. Supervisor Qualifications & Competence

L.01*, ** The organization retains experience supervisors who (1) hold a master’s or doctoral- level certification or license in behavior analysis or a related field from a nationally accredited certifying body, (2) meet the certifying body’s current standards for supervision, and (3) have at least one year of supervising cases or equivalent experience in accordance with certification or licensing standards. When applicable, supervisors should also be licensed in their state. (Aligns with ABAI, BACB®).

L.02*The organization outlines the nature and characteristics of supervision as required by certification and licensing bodies to potential experience supervisors. (Aligns with ABAI, BACB®, VCS)

L.03*, ** The organization ensures experience supervisors carry a caseload that enables them to facilitate effective supervision and treatment of patients and their trainees. (Aligns with ABAI, BACB®)

L.04*, ** The organization provides training to experience supervisors in the use of evidence-based practices for providing supervision and feedback to trainees. (Aligns with ABAI, BACB®, VCS)

L.05*The organization ensures the experience supervisor establishes a plan for structured fieldwork experience. (Aligns with ABAI, BACB®, VCS)

L.06*, ** The organization develops methods for evaluating supervisory effectiveness. (Aligns with ABAI, BACB®, VCS)

L.07* The organization reviews course syllabi and program expectations following acceptance of trainees to coordinate the trainee’s supervised fieldwork experience with coursework content and trainee’s demonstrated skill set. (Aligns with ABAI, BACB®)

L.08* The organization accepts trainees who have begun behavior analysis courses from an accredited program and/or those who have begun behavior analytic coursework from an approved and reputable but unverified or unaccredited university behavior analysis program. (Aligns with BACB®)

L.09* The organization verifies trainees’ certification or license status using a national certification or licensing registry, if applicable. (Aligns with BACB®)

M. Trainee Experience Documentation

M.01*The organization provides the trainee with a handbook outlining the supervision process, type of supervision (concentrated or independent fieldwork), supervision amount and structure, conditions for termination, responsibilities, and performance expectations. (Aligns with ABAI, BACB®)

M.02*The organization has a secure record system to document the relationship between the experience supervisor and trainee. (Aligns with BACB®)

M.03*The organization provides the trainee with the required supervision contract set forth by credentialing and licensing guidelines. (Aligns with ABAI, BACB®, VCS)

M.04*, ** The organization provides the trainee with verification of hours forms as dictated by certification and licensing bodies. (Aligns with BACB®)

M.05* The organization provides the trainee with documentation regarding terms of payment for supervision, if applicable. (Aligns with BACB®)

M.06* The organization has policies in place regarding trainees’ use of patient, parent/guardian and/or caregiver materials/information and/or images in educational activities, social media platforms, and live-streaming services. These policies first and foremost protect the privacy of the patients, parents or guardians, and caregivers. (Aligns with BACB®)

M.07* The organization has a plan to ensure it is prepared for continuity of supervision if an experience supervisor leaves the organization or their position. (Aligns with ABAI, BACB®, VCS)

M.08* The organization provides at least the minimal required hours for behavior technician training to the trainee as part of the onboarding process and ensures that the trainee becomes certified or licensed at the technician or paraprofessional level. (Aligns with ABAI)

M.09* The organization reviews all required certification and licensure documents with trainees and provides training on how to adhere to the experience hours. (Aligns with ABAI, BACB®)

M.10* The organization provides annual opportunities for trainees to renew video or photo releases and provides clear instructions regarding how to revoke consent, if requested, for the organization to use their image in training or marketing materials.

M.11* The organization has policies and procedures for communicating with trainees’ stakeholders (e.g., university personnel and supervisors). (Aligns with ABAI, BACB®)

N. Trainee Competence & Breadth of Experience

N.01* The organization conducts a baseline assessment of the trainee’s behavior analytic skills through formal and informal processes. (Aligns with ABAI, BACB®, VCS)

N.02*, ** The organization ensures that the required fieldwork experience skills are targeted and met in accordance with certification and licensure rules and guidelines. (Aligns with ABAI, BACB®, VCS)

N.03* The organization provides trainees with experiences in the treatment implementation process including collaboration and/or education of service recipients, parents/guardians, caregivers, and other professionals, in accordance with certification and licensure guidelines. (Aligns with ABAI, BACB®, VCS)

N.04* The organization provides the trainee with opportunities to advance to more complex behavior analytic skills. (Aligns with ABAI, BACB®, VCS)

N.05* The organization provides the trainee with opportunities to meet the correct ratio of direct-to- advanced and supervisory behavior analytic hours per certification and licensure guidelines. (Aligns with ABAI, BACB®, VCS)

N.06* The organization provides the trainee with opportunities to demonstrate ethical and professional conduct. (Aligns with ABAI, BACB®, VCS)

N.07* The organization provides the trainee with opportunities to develop supervision and management skills necessary for their level of certification or licensure. (Aligns with ABAI, BACB®, VCS)

N.08* The organization tracks the trainee’s overall skill development. (Aligns with ABAI, BACB®, VCS)

N.09* The organization provides opportunities to develop clinical care skills, professionalism skills, and interpersonal skills necessary to be successful in a professional position. (Aligns with ABAI, BACB®, VCS)

N.10* The organization utilizes competency-based training strategies throughout trainees’ fieldwork experience to teach behavior analytic skills consistent with best practices in the literature. (Aligns with ABAI, BACB®, VCS)

N.11* The organization ensures trainees carry a caseload that enables them to provide effective treatment for their patients. (Aligns with ABAI)

* These standards apply to organizations that are pursuing to add Training Site Accreditation to their Full Accreditation

** These items indicate Must Pass Standards.

2022 Telehealth Accreditation Standards

A. Ethics, Integrity, & Professionalism

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

D. Hiring, Training, & Retention

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

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

D.07 The organization utilizes a staff handbook.

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

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

E. Patient Intake

E.07 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 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.

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

F. Service Delivery

F.04 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.06** The organization has a process for prescribing data collection and analysis procedures including the types of data to be collected, the method of data collection, the frequency of data collection, procedures for ensuring reliability of data collection, and frequency of data analysis.

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

H. Collaboration & Coordination of Care

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.

I. Health, Safety, & Emergency Preparedness

I.02 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.06 The organization has a patient safety checklist that addresses location specific and patient specific safety considerations.

K. Security, Privacy, & Compliance

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.

O. Telehealth Service Planning

O.01 The organization has a designated technology officer who is responsible for the effectiveness of equipment and health information systems utilized in the delivery of telehealth services.

O.02** The organization conducts a screening of appropriateness for telehealth prior to initiating services.

O.03 The organization has a systematized process for telehealth session set up, including technological requirements, program requirements, and environmental prerequisites.

O.04 The organization has procedures that outline individualized, acceptable environment arrangements for telehealth services.

O.05 The Organization provides emergency management policies and procedures for software, hardware and other system resources that can be implemented during telehealth services.

** These items indicate Must Pass Standards. Evidence of having met these standards must be demonstrated during the evaluation in order to earn accreditation.

Do you have questions about our organization or becoming accredited?

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