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Domain 1: Agency Licensure
Active IBHS Certificate of Compliance (COC) on file
Agency holds a current COC issued by OMHSAS. COC specifies which service types are approved: Individual, ABA, and/or Group.
55 Pa. Code § 5240.11; 55 Pa. Code § 5240.5
Service description filed and current with OMHSAS
Written service description on file describes each approved service type, admission criteria, and geographic service area.
55 Pa. Code § 5240.5
Provider agreement with DHS active and current
Written provider agreement with the Department of Human Services is in place and renewed. Required for MA program enrollment.
55 Pa. Code § 1155.21
Agency organizational chart matches licensed scope
Organizational structure on file reflects the approved service types and identifies clinical director and governing body.
55 Pa. Code Chapter 5240; OMHSAS RCG, December 23, 2024
Quality improvement program documented and active
Written QI plan in place. Agency conducts and documents reviews of service delivery, outcomes, and staff performance.
55 Pa. Code Chapter 5240; OMHSAS RCG, December 23, 2024
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Domain 2: Staff Credentialing
Clinical Director holds required BCBA credential or PA licensure
Clinical director is a licensed PA behavior specialist, BCBA, or other NCCA/ANSI-accredited graduate-level behavior analysis credential holder, plus at least 2 years of ABA experience (required as of July 1, 2022).
55 Pa. Code § 5240.81; OMHSAS RCG, December 23, 2024
All Behavior Consultation (BC) staff meet qualification standard
Each BC staff member is a licensed PA behavior specialist, holds a BCBA or other NCCA/ANSI-accredited credential, or holds a graduate degree in ABA from an accredited institution.
55 Pa. Code § 5240.81
All BHT-ABA staff meet one of the 3 qualifying pathways
Each BHT-ABA staff member holds NCCA/ANSI-accredited behavior analysis certification, OR has completed a 40-hour RBT-Task-List training certified by a BCBA/BCaBA, OR has at least 2 years of ABA experience with 40 hours of DHS-approved ABA training.
55 Pa. Code § 5240.81
Staff personnel records retained for 4 years post-separation
Agency maintains documentation of credentials, qualifications, clearances, and training for every staff member for at least 4 years after the person leaves.
55 Pa. Code § 5240.42; OMHSAS RCG, December 23, 2024
All required PA background clearances current for every staff member
FBI, PA State Police, and Child Abuse History clearances on file and renewed per PA law for every staff member with direct consumer contact.
55 Pa. Code § 5240.12; OMHSAS RCG, December 23, 2024
Credentialing verification process documented for new hires
Written onboarding process confirms credential verification before new staff deliver services independently. Process applies to full-time, part-time, and contract staff.
55 Pa. Code § 5240.12; OMHSAS RCG, December 23, 2024
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Domain 3: Service Documentation
Initial assessment completed before or at service start
A written assessment of the child, youth, or young adult is completed and forms the basis for the Individualized Treatment Plan.
55 Pa. Code § 5240.21; 55 Pa. Code § 5240.22
Individualized Treatment Plan (ITP) completed within 30 days of service start
Written, strength-based ITP with individualized goals and objectives completed within 30 days of initiation of services for every consumer.
55 Pa. Code § 5240.22; 55 Pa. Code § 5240.86
ITP signed by consumer/guardian, treating staff, and clinical director
Every ITP and all updates bear dated signatures from the consumer (or parent/legal guardian for a child), the completing staff member, and a clinical director-qualified individual.
55 Pa. Code § 5240.22; OMHSAS RCG, December 23, 2024
Progress notes include all 4 required elements
Each progress note documents: progress (or lack thereof) toward goals, any new goals, any changes to existing goals or interventions, and new interventions added.
55 Pa. Code § 5240.22; OMHSAS RCG, December 23, 2024
Consumer records retained and accessible per DHS requirements
Individual records maintained and accessible to DHS representatives during reviews. Retention policy documented for case files and billing records.
55 Pa. Code § 5240.42; OMHSAS RCG, December 23, 2024
Incident reporting procedures in place and staff trained on them
Written incident reporting policy exists. All staff are trained on mandated reporting obligations and agency-specific incident reporting procedures.
55 Pa. Code Chapter 5240; OMHSAS RCG, December 23, 2024
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Domain 4: Ongoing Training Requirements
BC and MT staff complete at least 16 hours of DHS-approved training annually
Each individual providing behavior consultation or mobile therapy services completes at least 16 hours per year of Department-approved training related to job functions. Certification maintenance hours count toward this requirement.
55 Pa. Code § 5240.73; OMHSAS IBHS FAQ, 2020
New BHT staff complete at least 30 hours of training before independent service delivery
Any individual who provides Behavioral Health Technician services must complete at least 30 hours of DHS-approved training prior to delivering services without direct supervision.
55 Pa. Code § 5240.83; OMHSAS IBHS FAQ, 2020
Training records documented with dates, hours, and content for all staff
Agency maintains verifiable records for every training event: staff name, date, hours, content area, and trainer/provider. Records available for OMHSAS review.
55 Pa. Code § 5240.42; OMHSAS RCG, December 23, 2024
BCBA CEU renewal tracked and on schedule for all licensed clinical staff
Agency tracks BACB certification renewal cycles for every BCBA on staff. Renewal requires 32 CEUs per 2-year cycle including ethics and supervision hours. (Source: BACB Certificant Code, available at bacb.com/bcba.)
BACB Certification Maintenance Requirements, bacb.com/bcba
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Domain 5: Supervision Structure
Clinical director provides at least 1 hour of individual face-to-face supervision per month for ABA services
A clinical-director-qualified individual delivers at least 1 hour of individual, in-person supervision monthly. Supervision includes oversight of behavior analytic and behavior consultation-ABA services.
55 Pa. Code § 5240.82
BHT-ABA staff receive supervision at the required frequency
BHT-ABA staff working at least 37.5 hours per week receive 1 hour of supervision weekly. BHT-ABA staff working fewer hours receive at least 1 hour twice per month. Supervisor holds clinical director qualifications or BCBA/BCaBA-level credentials.
55 Pa. Code § 5240.82
Supervisory caseload does not exceed 12 FTE ABA staff (max 9 BHT-ABA) per supervisor
No individual supervisor carries more than 12 full-time-equivalent ABA staff. Of those 12, no more than 9 may be BHT-ABA staff.
55 Pa. Code § 5240.82
Supervision contacts documented with date, duration, participants, and content
Written supervision logs exist for every supervisory contact. Logs include date, duration, names of supervisor and supervisee, and topics covered. Available to OMHSAS on request.
55 Pa. Code § 5240.82; OMHSAS RCG, December 23, 2024
