2020 bhcoe preliminary accreditation self …...behavioral health center of excellence ©2020 2020...
TRANSCRIPT
Behavioral Health Center of Excellence
2020 BHCOE PRELIMINARY ACCREDITATION SELF-EVALUATION CHECKLIST
Behavioral Health Center of Excellence ©2020 2020 BHCOE Preliminary 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
Behavioral Health Center of Excellence ©2020 2020 BHCOE Preliminary 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.
Tally your score. _ Total your number of “Yes” responses and compare
your score with the chart below.
< 55 Needs improvement
56-59 On your way
60-63 Almost there
64 Preliminary accreditation
Behavioral Health Center of Excellence ©2020 2020 BHCOE Preliminary Accreditation Self-Evaluation Checklist | 4
Behavioral Health Center of Excellence 7083 Hollywood Boulevard #565, Los Angeles, CA 90028
Telephone 310-627-2746 www.bhcoe.org
THANK YOU FOR YOUR COMMITMENT TO CONTINUOUS QUALITY IMPROVEMENT