Behavioral Health Standard 2.A – Program/Service Structure


Each program / service:

  1. Documents the following parameters regarding its scope of services:
    1. Population served.
    2. Settings.
    3. Hours of service.
    4. Days of service.
    5. Frequency of services.
    6. Payers and funding sources.
    7. Fees.
    8. Referral sources.
    9. The specific services offered, including whether the services are provided directly or by referral.
  2. Shares information about the scope of services with:
    1. The persons served.
    2. Families / support systems, in accordance with the choices of the persons served.
    3. Referral sources.
    4. Payers and funding sources.
    5. Other relevant stakeholders.
    6. The general public.
  3. Reviews the scope of the services at least annually and updates it as necessary.
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The organization provides the resources needed to support the overall scope of each program / service.

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Based on the scope of each program / service provided, the organization documents its:

  1. Entry criteria.
  2. Transition criteria.
  3. Exit criteria.
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When a person served is found ineligible for services:

  1. The person served is informed as to the reasons.
  2. In accordance with the choice of the person:
    1. The family / support system is informed as to the reasons.
    2. The referral source is informed as to the reasons.
  3. Recommendations are made for alternative services.
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Service delivery models and strategies are based on accepted practice in the field and incorporate current research, evidence-based practice, peer-reviewed scientific and health related publications, clinical practice guidelines, and / or expert professional consensus.

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To facilitate integrated service delivery,each program / service implements communication mechanisms regarding the person served that:

  1. Address:
    1. Emergent issues.
    2. Ongoing issues.
    3. Continuity of services, including:
      1. Contingency planning.
      2. Future planning.
    4. Decisions concerning the person served.
  2. Ensure the exchange of information regarding the person-centered plan.
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The program / service demonstrates:

  1. Knowledge of the legal decision-making authority of the persons served.
  2. When applicable, the provision of information to the persons served regarding resources related to legal decision-making authority.
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When services are provided from or within a mobile unit, written procedures are implemented that address, at a minimum, the unique aspects of the following areas related to mobile settings:

  1. Responsibilities of:
    1. Drivers.
    2. Service providers.
  2. Confidentiality of:
    1. Records of persons served.
    2. Communication.
  3. Privacy related to service delivery.
  4. Accessibility.
  5. Availability of information on resources to address needs unable to be met at the mobile setting.
  6. Security of:
    1. Medications provided from or within the mobile unit, when applicable.
    2. Equipment and supplies used in service provision.
    3. The mobile unit when not in use.
  7. Safety of:
    1. Records of persons served.
    2. Personnel.
  8. Maintenance of:
    1. Equipment.
    2. Vehicles.
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Each core program for which the organization is seeking accreditation has a written program description that drives the delivery of services and includes:

  1. A description of the program.
  2. The philosophy of the program.
  3. Program goals.
  4. Service / treatment modalities to be provided to achieve the program objectives, including:
    1. Description of the service / treatment modalities.
    2. The credentials of staff qualified to provide the service / treatment modalities.
  5. Identification or a description of special populations and mechanisms to address their needs.
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Services are designed and implemented to:

  1. Support the recovery, health, or well-being of the persons of families served.
  2. Enhance the quality of life of the persons served.
  3. Reduce symptoms or needs and builds resilience.
  4. Restore and / or improve functioning.
  5. Support the integration of the persons served into the community.
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When applicable, there are policies and written procedures that address positive approaches to the program’s use of behavioral interventions, including:

  1. An emphasis on building positive relationships with persons served.
  2. Evaluation of the environment.
  3. Appropriate interaction with staff to:
    1. Promote de-escalation.
    2. Manage behavior.
  4. Empowering persons served to manage their own behavior.
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When applicable, the program implements:

  1. Written procedures governing the use of:
    1. Special treatment interventions.
    2. Restrictions of rights.
  2. Methods to ensure that intrusive procedures are administered in a safe manner, with consideration given to the:
    1. Physical history of the persons served.
    2. Developmental history of the persons served.
    3. Abuse history of the persons served.
  3. A process of regularly evaluating:
    1. Any restrictions placed on the:
      1. Rights of the persons served.
      2. Privileges of the persons served.
    2. Methods to reinstate restricted or lost:
      1. Rights of the persons served.
      2. Privileges of the persons served.
    3. The purpose or benefit of any type of restriction on rights or privileges.
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The program receives medical consultation regarding medically related policies or procedures, when appropriate.

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In a medically supervised program, there is a medical director who is a physician.

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The program offers one or more of the following:

  1. Peer support.
  2. Local advocacy groups.
  3. Consumer / survivor / ex-patient groups.
  4. Self-help groups.
  5. Other avenues of support.
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The program ensures that information and education that is relevant to the needs of the persons served is provided.

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Families are:

  1. Encouraged to participate in educational programs offered by the organization.
  2. Invited to participate in clinical programs or services with the persons served, with consent or legal right.
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Written procedures specify that the program provides or arranges for crisis intervention services.

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To meet the needs of the persons served, the program demonstrates how it uses technology to:

  1. Increase access to services.
  2. Increase support.
  3. Enhance services.
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For personnel providing direct services, the organization includes the following in its assessment of competency and competency-based training:

  1. Areas that reflect the specific needs of the persons served.
  2. Clinical skills that are appropriate to the position.
  3. Person-centered plan development.
  4. Interviewing skills.
  5. Program-related research-based treatment approaches.
  6. Identification of clinical risk factors, including:
    1. Suicide.
    2. Violence.
    3. Other risky behaviors.
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Team members, in response to the needs of the persons served:

  1. Help empower each person served to actively participate with the team to promote recovery, progress, or well-being.
  2. Provide services that are consistent with the needs of each person served through direct interaction with that person and / or with individuals identified by that person.
  3. Are culturally and linguistically competent.
  4. Meet as often as necessary to carry out decision-making responsibilities.
  5. Document:
    1. The attendance of participants at team meetings.
    2. The result of team meetings.
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A designated individual(s) assists in coordinating services for each person served by:

  1. Assuming responsibility for ensuring the implementation of the person-centered plan, if applicable.
  2. Ensuring that the person served is oriented to his or her services.
  3. Promoting the participation of the person served on an ongoing basis in discussions of his or her plans, goals, and status.
  4. Identifying and addressing gaps in service provision.
  5. Sharing information on how to access community resources relevant to his or her needs.
  6. Advocating for the person served, when applicable.
  7. Communicating information regarding progress of the person served to the appropriate persons.
  8. Facilitating the transition process, including arrangements for follow-up services.
  9. Involving the family or legal guardian, when permitted.
  10. Coordinating services provided outside of the organization.
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The organization implements a policy and written procedures for the supervision of all individuals providing direct services.

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Documented ongoing supervision of clinical or direct service personnel addresses:

  1. Accuracy of assessment and referral skills.
  2. The appropriateness of the treatment of service intervention selected relative to the specific needs of each person served.
  3. Treatment / service effectiveness as reflected by the person served meeting his or her individual goals.
  4. Risk factors for suicide and other dangerous behaviors.
  5. The provision of feedback that enhances the skills of direct service personnel.
  6. Issues of ethics, legal aspects of clinical practice, and professional standards, including boundaries.
  7. Clinical documentation issues identified through ongoing compliance review.
  8. Cultural competency issues.
  9. Model fidelity, when implementing evidence-based products.
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The program implements policies and procedures that address:

  1. The handling of items brought into the program:
    1. By:
      1. Persons served.
      2. Personnel.
      3. Visitors.
    2. Including:
      1. Illegal drugs.
      2. Legal drugs.
      3. Prescription medications.
      4. Weapons.
  2. The use of tobacco products in all:
    1. Locations.
    2. Vehicles owned or operated by the organization.
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Programs that treat persons with substance use disorders implement written procedures that address the use of drug screening, including:

  1. An individualized approach with frequency based on the needs of the person served.
  2. Specific treatment conditions that would warrant drug screening.
  3. Collection of specimens in a respectful manner.
  4. Ensuring that drug screening results are not used as the sole basis for:
    1. Treatment decisions.
    2. Termination from treatment.
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The organization implements policies and procedures that are inclusive of a peer workforce.

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Peer support specialists assist in peer support services:

  1. Design.
  2. Development.
  3. Implementation.
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The organization demonstrates a climate of recovery and / or resilience building by:

  1. Respecting the unique role of peer support specialists.
  2. Training personnel on the role of peer support specialists.
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Peer support specialists receive documented competency-based training that:

  1. Is based on a recognized peer-support curriculum or a curriculum designed and developed with the input of peer support specialists.
  2. Is provided with the involvement of peer support specialists, as applicable.
  3. Includes:
    1. Initial training on the following topics:
      1. Personal advocacy.
      2. Engagement.
      3. Recovery and resiliency principles.
      4. Community supports / connections.
      5. The effective use of sharing life experiences.
      6. Parenting skills, as applicable.
    2. Ongoing training on current practices in peer support services.
  4. Is provided in a manner that is:
    1. Understandable.
    2. Appropriate to the developmental age of the peer support specialists being trained.
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The organization’s written ethical codes of conduct specifically address boundaries related to peer support services.

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Based on the needs and preferences of the persons served, peer support:

  1. Is provided consistent with or complimentary to the person’s identified plan, when applicable.
  2. Includes the following direct service activities performed by peer support specialists, as applicable:
    1. Engaging the person served.
    2. Supporting personal recovery goals or building on resiliency.
    3. Community networking.
    4. Advocating with and for the person served.
    5. Parenting skills.
    6. Mentoring.
    7. Bridging or navigating.
  3. Includes the following educational activities for the persons served, as applicable:
    1. Self advocacy.
    2. Wellness.
    3. Life skills.
    4. Goal setting.
    5. Decision-making skills.
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Peer support services are provided in locations that meet the needs of persons served.

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