TITLE 55. HUMAN SERVICES

CHAPTER 5240 INTENSIVE BEHAVIORAL HEALTH SERVICES

REGULATORY COMPLIANCE GUIDE

(November 26, 2024)

Office of Mental Health and Substance Abuse Services
(OMHSAS)

INTRODUCTION

On October 19, 2019, 55 Pa. Code Chapter 1155 (relating to intensive behavioral health services) and 55 Pa. Code Chapter 5240 (relating to intensive behavioral health services) became effective.  These regulations govern the payment and operation of Intensive Behavioral Health Services (IBHS) in the Commonwealth of Pennsylvania. In most cases, the regulations speak for themselves. There are, however, some regulatory provisions that require additional clarification. Even when the regulatory requirement is very clear, the purpose and intent of the requirement may not be.  There can also be inconsistencies in how regulations are interpreted, and both providers and OMHSAS Licensing Representatives need to know how compliance will be determined. This Regulatory Compliance Guide is meant to help providers and OMHSAS Licensing Representatives better understand the regulations.

This guide is a companion piece to 55 Pa. Code Chapter 5240; it is intended to be a helpful reference for these regulations. The explanatory material contained in this guide in no way supplants the plain meaning and intent of the regulations set forth in 55 Pa. Code Chapter 5240.

In addition, this guide has been developed to provide clear explanations of the regulatory requirements of 55 Pa. Code Chapter 5240 to help agencies providing intensive behavioral health services provide safe environments and effective services to individuals through regulatory compliance, and to help OMHSAS Licensing Representatives protect individuals by conducting consistent and comprehensive inspections. It provides a detailed explanation of each regulatory requirement, including expectations for compliance, guidelines for measuring compliance, and the primary purpose for the requirement.  Finally, this guide includes general regulatory requirements and procedures, and overviews of complex regulatory issues to provide a more global understanding of the chapter and its purpose.

Table of Contents

REGULATION	PAGE
PART 1: An Introduction and Overview of Regulatory Process	6
How to Use the Regulatory Compliance Guide	7
Overview of the Licensing Process	8
The Plan of Correction	12
Waivers	14
Occupancy Permits	16
PART 2: Regulations, Discussions, and Inspection Procedures	17
GENERAL PROVISIONS	18
§ 5240.1. Scope.	18
§ 5240.2. Definitions.	19
§ 5240.3. Provider eligibility.	25
§ 5240.4. Organizational structure.	26
§ 5240.5. Service description.	27
§ 5240.6. Restrictive procedures.	29
§ 5240.7. Coordination of services.	36
STAFFING	38
§ 5240.11. Staff requirements.	38
§ 5240.12. Staff qualifications.	41
§ 5240.13. Staff training plan.	44
§ 5240.14. Criminal history checks and child abuse certification.	46
SERVICE PLANNING AND DELIVERY	48
§ 5240.21. Assessment.	48
§ 5240.22. Individual treatment plan.	53
§ 5240.23.  Service provision.	59
DISCHARGE	60
§ 5240.31. Discharge.	60
§ 5240.32. Discharge summary.	62
RECORDS	63
§ 5240.41. Individual records.	63
§ 5240.42. Provider records.	66
§ 5240.43. Record retention and disposal.	67
NONDISCRIMINATION	67
§ 5240.51. Nondiscrimination.	67
QUALITY IMPROVEMENT	68
§ 5240.61. Quality improvement requirements.	68
INDIVIDUAL SERVICES	70
§ 5240.71. Staff qualifications for individual services.	70
§ 5240.72. Supervision of staff who provide individual services.	74
§ 5240.73. Training requirements for staff who provide individual services.	80
§ 5240.74. Individual services initiation requirements.	85
§ 5240.75. Individual services provision.	86
APPLIED BEHAVIOR ANALYSIS	88
§ 5240.81. Staff qualifications for ABA services.	88
§ 5240.82. Supervision of staff who provide ABA services.	95
§ 5240.83. Training requirements for staff who provide ABA services.	102
§ 5240.84. ABA services initiation requirements.	106
§ 5240.85. Assessment.	107
§ 5240.86. Individual treatment plan.	111
§ 5240.87. ABA services provision.	117
GROUP SERVICES	119
§ 5240.91. Staff requirements and qualifications for group services.	119
§ 5240.92. Supervision of staff who provide group services.	120
§ 5240.93. Training requirements for staff who provide group services.	125
§ 5240.94. Group services initiation requirements.	129
§ 5240.95. Assessment.	131
§ 5240.96. Individual treatment plan.	133
§ 5240.97. Group services provision.	139
§ 5240.98. Requirements for group services in school settings.	141
EVIDENCE-BASED THERAPY	145
§ 5240.101. EBT initiation requirements.	145
§ 5240.102. Assessment and individual treatment plan.	146
§ 5240.103. Requirements for EBT delivered through individual services, ABA services or group services.	148
WAIVERS	151
§ 5240.111. Waivers.	151
PART 3: Relevant Bulletins	153
PART 4: Additional Resources	157
Bureau of Equal Opportunity Civil Rights Compliance – General Process	158
Bureau of Equal Opportunity Civil Rights Compliance – Additional Instructions	158
Electronic Record Keeping	160
Shared Space/Co-Location Attestation	161
Shared Space/Co-Location Attestation Form	162

PART 1:

An Introduction and Overview of the Regulatory Process

How to Use the Regulatory Compliance Guide

This Regulatory Compliance Guide was developed to provide explanations of the regulatory requirements of 55 Pa. Code Chapter 5240. This guide is intended to help licensed providers to provide safe environments and effective services to individuals in treatment through regulatory compliance. Further, this guide was created to assist OMHSAS Licensing Representatives in conducting consistent and comprehensive inspections. This guide provides a detailed explanation of regulatory requirements including, explanations for compliance, guidelines for measuring compliance, and the primary benefit of the requirement.

Each regulation that is measured during an inspection is included in the Regulatory Compliance Guide and is accompanied by clarifying information. The illustration below shows how regulations are presented and how OMHSAS Licensing Representatives and providers can effectively use this guide.

This area lists the regulation exactly 

as it appears in Chapter 5240.

The “Discussion” section provides

information about applying the

regulation, including referencing other

regulations and applicable narratives.

The “Inspection Procedures” section

describes how Representatives

may measure compliance with the

regulation.

The “Primary Benefit” section

explains how the regulation protects

individuals in treatment, including:

health, safety, and well-being.

Regulation: § 5240.2. Definitions. Full-time equivalent—37.5 hours per week of staff time. Discussion: The Department interprets the regulatory definition of Full-time equivalency (FTE) to include time spent in both direct service provision and non-billable activities related to behavioral health services. When determining if an individual who provides IBHS services works a full-time equivalent, the IBHS provider should include all hours the individual is considered to be working for the IBHS provider. Inspection Procedures: OMHSAS Licensing Representatives will the program information form, and may review staff rosters, staff schedules, and other documentation as needed. Primary Benefit: Ensures a standardized definition of what is considered a full-time equivalent.

Suggestions

Throughout the guide, the words “OMHSAS suggests” are seen repeatedly. This phrase indicates that what is written is a suggestion based on best practices, not a regulatory requirement. Failure to follow a recommendation will not result in a regulatory violation.

Inspection Procedures

Please note that the “Inspection Procedures” are guidelines, and the specific means of measuring compliance with a regulation may differ depending on circumstances specific to the facility, the reason for the inspection, and the nature of the regulatory violation. 

Overview of the Licensing Process

55 Pa. Code Chapter 20 provides the authority to the Department to issue, deny, renew or not renew, and revoke Certificates of Compliance (COC), and to conduct inspections. The following section outlines the processes that OMHSAS Licensing Representatives will follow, as the situations allow, for initial, renewal, complaint, or incident inspection. Inspections can be announced and unannounced.

Initial Licensing Process

Providers must receive a COC to provide IBHS services. The DHS licensing website includes all the documents (licensing application and instructions) that are required to submit an initial license application or annual renewal.

Components of a Certificate of Compliance

The COC includes the legal entity name, the facility name and address (primary location), and any additional service locations. It additionally lists the services that the IBHS provider is approved to provide (Individual, ABA, Group) and the effective date span of the COC. The COC is renewed on an annual basis as outlined in 55 Pa Code Chapter 20.31.

The service locations that are added to the COC include: center-based one-to-one and the locations where Group services are provided (not including locations that are operated in a community setting where a certificate of occupancy is unavailable, for example in a public park). Examples of Group services locations that are added to the COC include, but are not limited, schools, community settings such as a library or community center and community like locations. An onsite inspection must occur before any service location can be added to the COC. Any additional questions on this process should be directed to the applicable OMHSAS field office or the assigned OMHSAS Licensing Representative. 

The COC will not list locations where Individual services are provided in the school setting and not part of a Group school-based provider, or locations where 1:1 services are provided in the community and not part of a larger Group provider. Additionally, any provider facility where IBHS services are not provided, such as an office building where supervision and training occurs, will not be added to the COC, unless this is the provider’s primary location. Provider facilities not included on the license should appear on the provider’s approved service description. 

Annual Licensing Visit Preparation

Prior to an announced licensing visit, OMHSAS Licensing Representatives will provide the Intensive Behavioral Health Services provider with the following:

• A letter/e-mail confirming the date and time of the licensing visit and provide a list of documents that will need to be reviewed when on-site.
• A confirmation of location where the licensing visit will occur and a request for a workspace in the facility where OMHSAS Licensing Representatives may work in private. If the clinic maintains electronic records, a computer to access these records should be available for each Representative who will be present.
• The pre-inspection documents including the provider information form and CPSL tracking form. The provider should complete and return to the OMHSAS Licensing Representative prior to the licensing visit.

Conducting the Entrance Conference

During the entrance conference, OMHSAS Licensing Representatives will: 

• Facilitate introductions that include name and title.
• Briefly state the purpose of the inspection. 
• Discuss the agenda for the day.
• Request a point of contact and discuss a way to maintain communication throughout the visit.
• Provide an opportunity for the director or clinical supervisor to give updates on the provider to inform of any changes, issues, successes that occurred since the previous licensing visit, and ask any questions.
• Discuss waivers or policy updates as needed.

Source of Inspection

Compliance with regulations can be measured through three methods:

• “On-site” – Direct observation during an on-site inspection. This includes direct observation using all five senses. Site observations include, but are not limited to, the physical inspection of staff offices, conference room(s), waiting room(s), rooms used to provide therapy, and the room(s) where medication may be stored and/or dispensed. This is conducted to assure compliance with Federal, State, and local requirements for safety, fire, accessibility, health, and medication.
• “Records” – Inspection of written documents. This may include, but is not limited to, an inspection of written and electronic materials, photographs, and other paper and electronic materials.
• “Interview” – Asking questions for further insight into how services are provided and how regulatory requirements are met. This may include, but is not limited, to the following: Directors, Supervisors, staff members, and individuals receiving treatment. 

Records

The following minimum number of records for staff and individuals in treatment should be reviewed for each facility. Additional records should be reviewed if there is reason to suspect violations, or if the minimum sample is not representative of the population served or of the various staff positions.

For records of individuals in treatment, a variety of records are selected to provide an accounting of the different services and populations served by the facility. Selected records will account for, but are not limited to, the following: main location and additional locations where services are provided (including center-based and community-based services), all types of services provided (ABA, Individual, Group Services, and Evidence-Based Treatment). The OMHSAS Licensing Representatives assigned to work with the facility will request information prior to the inspection to help in their selection of individual records.

OMHSAS Licensing Representatives will review a minimum of 12 individual records. Of these 12, two should be records of individuals who have been discharged. OMHSAS Licensing Representatives will review additional files as necessary for a variety of other factors.

For staff records (HR files), OMHSAS Licensing Representatives review these records to determine whether staff meet position qualification requirements, and have all required clearances, supervision and trainings.

• For newly licensed providers, all staff records will be reviewed during the initial site visit.
• For established providers, the staff records of all staff members who have been hired  or promoted in the period following the previous site visit will be reviewed. This includes any staff member who has left the provider during this timeframe. At least 10 percent of all tenured staff files should be reviewed. 
• OMHSAS Licensing Representatives will review additional files as necessary for a variety of other factors.

OMHSAS Licensing Representatives will also review additional records; these records will be either requested prior to, or during the on-site inspection. This includes, but is not limited to, the following: current description of services, organizational chart, current waivers, changes in policies and procedures, documentation of trainings and supervision, quality improvement plans and reports, and written agreements to coordinate services.

Conducting the Exit Conference

If the inspection will last more than one day, OMHSAS Licensing Representatives will conduct a partial exit conference with the director or clinical supervisor at the end of each day on-site.  OMHSAS Licensing Representatives will explain the progress of the inspection, including what has been and what remains to be done and when OMHSAS will return to complete the inspection. 

Prior to conducting the final exit conference, OMHSAS Licensing Representatives will:

• Review the provider using the Chapter 5240 IBHS regulations along with the corresponding survey tool to ensure that compliance has been measured in all areas.
• Confer with any accompanying OMHSAS Licensing Representatives on preliminary findings (strengths, recommendations, citations).
• Notify the facility of the time and place of the exit conference at least one hour prior to the full exit conference, whenever possible.

During the final exit conference, OMHSAS Licensing Representatives will:

• Allow the facility to include any staff they wish to have present.
• Allow the facility a chance to provide additional information or clarification when needed.

• Remind attendees that the purpose of the conference is to provide preliminary findings.  
• Review each citation found, provide the rationale for each regulation cited, provide technical assistance, and discuss the Plan of Correction (POC) process.
• Explain that all citations should be reviewed by an OMHSAS supervisor before being recorded on a written licensing inspection summary (LIS) and sent to the facility.
• Refer to appropriate local or State training sources, as needed.
• Provide forms, technical assistance materials, and other documents to assist with compliance. 
• Explain the next steps in the licensing process (preparation and mailing of the LIS, POC submission by the facility, review of POC, follow-up on the POC as needed, recommendation re: licensure).
• Explain that the OMHSAS Community Provider Managers/Regional Director makes all decisions regarding license issuance or enforcement action.

During the final exit conference, OMHSAS Licensing Representatives will NOT: 

• Make preliminary recommendations for licensing actions (i.e. issuance of a provisional license).
• Speculate regarding possible licensing outcomes. 
• Make statements of value judgments about the facility’s appearance, operations, or staff.

Other Licensing Visits

In addition to initial and annual licensing visits, 55 Pa Code Chapter 20.33 gives the Department the authority to conduct announced and unannounced on-site investigations, and complaint investigations. Announced and unannounced on-site inspections are often, but not required to be, conducted after an event that jeopardized the health and safety of an individual served by the program, or after a sentinel event has occurred. Complaint investigations are conducted by the Department when a complaint is received. Chapter 20.34 requires providers to allow full access to the facility or agency and its records during these investigations.

OMHSAS Licensing Representatives will prepare to conduct these inspections by determining what questions need to be asked, to whom these questions should be asked, what documents need to be attained and reviewed, and if any immediate actions need to be taken. Supervisors will be consulted if there is uncertainty at any point in the investigative process. To conduct these investigations, the OMHSAS Licensing Representative may request to review files such as individual records, policies and procedures relevant to the investigated issue, video footage, and other applicable files. 

During an announced or unannounced on-site investigation, OMHSAS Licensing Representatives will conduct an entrance conference similar to an initial or annual licensing visit, with a focus on identifying the relevant staff, individuals, and resources needed to conduct the investigation. Following an on-site investigation, it is not always possible to conduct a full exit conference since further research may be needed. In such cases, a preliminary exit conference may be conducted to allow OMHSAS Licensing Representatives the opportunity to discuss any immediate actions that should occur, and to outline the next steps in the process of the investigation.

During a complaint investigation, it is not always necessary for the OMHSAS Licensing Representative to complete the investigation on-site.  OMHSAS Licensing Representatives will contact the complainant to discuss their complaint and, when not conducting an on-site visit as outlined above, contact the provider to give an overview of the complaint, ask relevant questions, and request files for review. 

At the conclusion of any investigation, OMHSAS Licensing Representatives will contact the provider to inform them of the results of the investigation and provide any recommendations or deficiencies found during the investigation.

Frequency of OMHSAS Inspections of Service Locations

While the regulation uses the term “site” related to a facility, it is common practice that OMHSAS Licensing Representatives use the term “service location” for any locations

that are not deemed the primary location on the COC. 

OMHSAS Licensing Representatives are required to inspect a licensed provider annually. OMHSAS Licensing Representatives will conduct an initial review of all service locations that will be included on the COC prior to the provision of service at the location. They are additionally expected to ensure all locations that appear on the COC, including the primary location and additional service locations, are visited at least every year. OMHSAS licensing staff may rotate the location at which they complete the yearly onsite inspection to ensure all sites are seen within the three-year period.

The Plan of Correction

The Department of Human Services (DHS) has created a consistent approach to licensing throughout DHS which ensures that every POC is implemented timely to protect the ongoing safety and well-being of those served by a provider. This process is outlined in DHS Bulletin 14-Bul-107 and below.

The Plan of Correction Process

1. If any licensing violations are found during an on-site inspection or investigation, an LIS with identified deficiencies will be issued. An attempt will be made to issue the LIS within 15 business days of the date of the exit conference.

2. In response to the LIS, the provider shall return an acceptable POC to the assigned OMHSAS Licensing Representative no later than 10 calendar days after the LIS was sent to the provider. Based upon the violation, OMHSAS may request the POC be submitted earlier than 10 calendar days after the LIS was sent to the provider.

3. An acceptable POC should include, at a minimum, concrete and measurable corrective actions to address each specific violation, including any measures or systemic changes to ensure the licensing violation will not reoccur.

4. OMHSAS either accepts or does not accept the POC. OMHSAS will attempt to accept or not accept the POC within 10 business days from the receipt of the POC.

5. If OMHSAS does not accept the POC, then the provider shall submit a second, revised POC. The provider should submit the second, revised POC within five business days (or less if OMHSAS determines it necessary) of the date of the notice that the first POC was unacceptable.

6. Upon receipt of the second, revised POC, OMHSAS either accepts or does not accept the POC. OMHSAS will attempt to accept or not accept the second, revised POC within five business days of the receipt of the second, revised POC.

7. If OMHSAS does not accept the second, revised POC, then OMHSAS may direct the POC, or may take further licensing action, which could include revocation or refusal to renew the COC, or issuance of a provisional COC. OMHSAS will attempt to notify the provider within 10 business days from the date the second POC was determined not acceptable.

8. Upon acceptance of the POC, OMHSAS will send a written notification to the provider that the POC is acceptable. OMHSAS’ acceptance of a POC only serves as OMHSAS’ acknowledgement of the provider’s willingness to adequately and timely correct the licensing violations. Acceptance of a POC did not and does not absolve the provider of the obligation to achieve and maintain compliance, nor does it confirm that the provider is compliant with licensing requirements. 

9. OMHSAS verifies compliance by an on-site reinspection or by reviewing documentation that was submitted by the provider and that conclusively demonstrates the POC was implemented, compliance was achieved and is being maintained. 

10. The timeframe for verification of compliance should be based upon how the regulatory violations may impact the health and safety of individuals. OMHSAS will attempt to re-inspect those violations that pertain to serious health and safety issues within five business days after the implementation date of the POC for that specific violation. For all other compliance issues, OMHSAS will attempt to re-inspect or review documents within 30 calendar days after the last implementation date specified in the POC. By way of further explanation on the 30-day timeframe, if a POC contains multiple items and plans responsive to an LIS, then the latest date should be used when determining the timeframe for completing the re-inspection. Nothing in this guidance precludes an OMHSAS Licensing Representative from conducting on-site monitoring visits before the specific implementation date of the POC or any item within the POC.

11. If, upon reinspection or document review, OMHSAS finds that the provider has achieved and is maintaining compliance, then OMHSAS will notify the provider in writing and issue a new annual COC. OMHSAS will also update, accordingly, any documents posted to the web to indicate that the POC has been implemented and the licensee has achieved compliance.

12. If OMHSAS finds that a POC has not been fully implemented or the provider has not achieved and maintained compliance with any licensing requirements, then OMHSAS will issue a provisional COC unless there is an extraordinary circumstance.

Please note, nothing in this process limits OMHSAS in any way from taking other licensing actions, as OMHSAS finds appropriate, pursuant to applicable law.

Elements of an Acceptable Plan of Correction 

Regulations are necessary to ensure the safety and well-being of those that we serve. It is important that this is kept in mind as a provider writes a POC. To help provide all the elements needed in a POC, the following sections have been created to assist the provider in writing an acceptable POC. 

Why did it happen? Understanding why the violation happened is critical to keep it from happening again. Sometimes the most easily identifiable cause may not be the real reason the violation occurred. One way a provider can identify the root cause of the problem is by asking “why” multiple times. This is a very simple approach for identifying each violation’s source.

What do you do now to fix the problem? When writing your immediate solution, address who is responsible for fixing the problem and monitoring compliance, what action that person will take, and when that action will happen. The solution needs to be realistic, sustainable, and specific. 

How do you prevent this from happening again?  The goal of the POC is not only to fix the violation, but to make sure there is a sustainable plan in place to keep it from happening again. These long-term solutions should greatly reduce or eliminate the chances of the violation happening again and do it in a manner that is sustainable over time. The POC should detail specific, realistic, actionable steps that keep the violation from happening again.

Provider’s Plan of Corrective Action / Projected Dates of Completion. The provider’s plan of corrective action includes itemized steps that are needed to fix the violation and prevent it from happening again. It clearly denotes each specific, realistic, and actionable step, and the person responsible for implementing each step. The column entitled ”Provider” under the heading ”Projected Dates of Completion” on the LIS is where the providers list the date(s) each step in the plan of correction will be completed.  

Waivers

Occasionally, an Intensive Behavioral Health Services provider is unable to comply with a regulation due to the structure, operation, or population served.  It is for this reason that providers are permitted to request waivers of certain regulations.  When waivers are approved, additional conditions may apply. Intensive Behavioral Health Services providers must comply with all regulations unless a waiver has been approved.  Submitting a request for a waiver does not permit noncompliance, nor is a plan to submit a waiver an acceptable POC for a regulatory violation. 

Requesting a Waiver

In order to request a waiver, providers must follow the most follow the requirements of the most updated version of the waiver bulletin. The bulletin contains the documents required for submission of the waiver request. Providers can find current bulletins on the DHS website. Additionally, a written response from the County MH/IDD Administrator(s) approving the waiver request must be submitted to the regional OMHSAS Field Office.

Determinations may be delayed or denied if all of the information required is not included in the waiver request form.

The Waiver Decision 

Facilities and agencies should not consider the submission of a waiver request to mean that it is approved and that they are excused from following the regulation. Instead, facilities or

agencies must comply with the regulation as it is written unless and until they receive a written notice that the waiver has been approved, along with any additional conditions of the approval.

If the waiver is granted, the Department will specify the length of time for which the waiver is granted and any conditions that the facility must meet.

If the waiver is denied, facilities have the right to appeal. Instructions for filing an appeal will be included in the denial letter.

Waiver Denials, Renewals, and Revocations 

Agencies may also request renewal of an approved waiver.  It is recommended that requests for continuation of the waiver be submitted to the assigned OMHSAS Licensing Representative 60 days in advance of the approved waiver’s expiration date or 60 days prior to the date of license renewal, whichever is earlier to be consistent with 55 Pa. Code Chapter 20 requirements around reapplication. Requests for renewal must include a letter of support from the County MH/IDD Administrator(s).

Agencies may appeal adverse rulings (such as denials) regarding requests for waiver.  Appeals are directed to:

OMHSAS Bureau of Policy, Planning & Program Development 

ATTN: Waiver Appeals

P.O. Box 2675 

Harrisburg, Pennsylvania 17105

or: RA-PWOMHSASWAIVERS@pa.gov    

Any appeal must be in writing and must be received within 30 days of the mailing date of the letter being appealed.

The Department may revoke a waiver at any time if the conditions required by the waiver are not met, if conditions have not been met on a continual basis or if there is a risk to the health, safety, or well-being of the individuals served.  

Occupancy Permits

Agencies that wish to begin providing services, or wish to provide services at a location that is not on their current certificate of compliance, must submit an occupancy permit for this new location. The address on the occupancy permit must exactly match the address of the location where the services will be provided. A post office box is not accepted for a program facility address; rather, the street address is required. If the address has been changed, the agency should speak with either the Post Master or Emergency Medical Services (911) and request this be explained in written form. The agency could also check with the county organization that issued the permit to verify whether it has a permit with the updated address. Occupancy permits must list the address of the structure, the name of the building official, the use code, and the maximum occupancy. One of the following is required for the main site and satellites:

•  A copy of the Department of Labor and Industry (L&I) Certificate.  

•  Pittsburgh, Philadelphia, Scranton or participating Municipality Occupancy Certificate (after April 9, 2004) under the Uniform Construction Code (UCC) for the building in which the program is located.  A list of UCC participating municipalities is available online. 

•  A report from a private inspection service stating the results of its review, along with the credentials of the inspector and the criteria by which the review was conducted.

Occupancy Permits for a Provider Operating out of a Residential Home

Some IBHS agencies may operate their business out of a residential home with no additional provider offices. In such a case, the address of the residence will appear on the certificate of compliance as the primary location of the facility or provider. An occupancy permit is required when adding the location to the certificate of compliance. When the municipality in which the residence is located does not grant occupancy permits for residential buildings, the IBHS provider must provide evidence that the municipality does not require such permits. The IBHS provider will need to coordinate with the OMHSAS regional field office to request a waiver of 55 Pa Code Chapter § 20.35 [related to fire safety approval] to allow the issuance of a certificate of compliance without an occupancy permit. The annual on-site inspection required per 55 Pa Code Chapter § 20.31 [related to annual inspections] will be conducted at the residential home. 

It may be possible that an IBHS provider is unable to obtain an occupancy permit for reasons other than operating out of a residential home. In these cases, the waiver process outlined above should be followed.

PART 2:

Regulations, Discussion,

and Inspection Procedures

GENERAL PROVISIONS

Regulation: § 5240.1. Scope. This chapter applies to entities that provide intensive behavioral health services (IBHS), as defined in this chapter, to children, youth or young adults and sets forth the minimum requirements that shall be met for a provider to obtain a license to provide one or more IBHS. Discussion: This section of the regulation was developed to identify the entities which provide services that fall under the scope of the IBHS regulations. In order to assure providers are properly licensed, it is important to know if the services that are provided fall under the IBHS regulation. For example, licensed mental health providers that utilize ABA as a modality in their treatment do not need an IBHS license. This may include, but is not limited to: psychiatric outpatient clinics, partial hospitalization providers, residential treatment facilities, and family based mental health service providers. In another example, services that are licensed through another Commonwealth provider, such as Department of Education, do not require an IBHS license. Providers who have questions about the requirement to obtain an IBHS license should contact their regional OMHSAS Field Office for assistance. It is important to note that the provision or non-provision of services to individuals who receive medical assistance has no bearing on the requirement to obtain an IBHS license. Providers that obtain an IBHS license but do not provide any services would not be in compliance with § 5240.1(a), since the scope only applies to entities which provide services. Inspection Procedures: For agencies who may require an IBHS license, OMHSAS Licensing Representatives will assist the provider during the initial licensing process to determine if the provider provides services that will require an IBHS license to be obtained. After an IBHS license is issued, OMHSAS Licensing Representatives will review the program information form and documentation that identifies individuals receiving services and the services they receive to ensure the entity is providing IBHS services.  Primary Benefit: Ensures that agencies that provide IBHS services, as defined in this regulation, are properly licensed and provide IBHS services.

Regulation: § 5240.1. Scope. This chapter does not apply to individual licensed practitioners or group arrangements in which only licensed practitioners provide IBHS. Discussion: Licensed practitioners or group arrangements who provide services directly within the scope of their license do not need to obtain an additional license to provide IBHS or to receive payment for the services provided. For example, a practitioner who provides behavioral interventions within the scope of their license does not need to obtain an IBHS license to continue to provide services to a child, youth, or young adult. However, if the practitioner employs staff who provide IBHS such as behavioral health technician (BHT) services, behavior consultation (BC) services or mobile therapy services(MT), the practitioner’s provider would need to obtain an IBHS license. If a group of practitioners need to obtain a license to provide IBHS because they are employing staff that provide IBHS, the practitioners should follow the same process as all other providers for obtaining a license as an IBHS provider. Inspection Procedures: OMHSAS Licensing Representatives will assist licensed individual practitioners or group arrangements during the initial licensing process to determine if a license is needed to provide IBHS services; organizational charts and pre-licensure documentation outlining staffing will be reviewed. Primary Benefit: Ensures that licensed practitioners can continue to work within the scope of their license through the PA Department of State without requiring an additional license through DHS.

Regulation: § 5240.2. Definitions. ABA – Applied behavior analysis – The design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior or to prevent loss of attained skill or function including the use of direct observation, measurement and functional analysis of the relations between environment and behavior. Discussion: The certificate of compliance for IBHS licensed providers will identify the specific services in which they are licensed to provide; Individual, ABA, Group.  In order to provide ABA, staff must have the required qualifications and credentials as outlined in § 5240.81. ABA service provision is outlined in this definition. It is important to note that Individual, Group and EBT service may utilize some of the same modalities that are used in ABA. If a provider is unsure whether ABA services should appear on their certificate of compliance, they should contact their regional OMHSAS Field Office for assistance. Inspection Procedures: For agencies seeking an IBHS license, OMHSAS Licensing Representatives will review the initial service description and the program information form to assure ABA services provided align with the definition. Primary Benefit: Ensures that ABA services are provided in a manner consistent with the established definition.

Regulation: § 5200.2. Definitions. Community like setting—A setting that simulates a natural or normal setting for a child, youth or young adult. Discussion: IBHS services provided in a community like setting can be delivered in a group or on a one-to-one basis. An IBHS provider’s center(s) may be considered a community like setting if the center(s) meets the definition in this section. Requirements to provide center-based one-to-one IBHS services can be found in the bulletin titled OMHSAS-21-02. The locations where services are provided in a community like setting must be listed on the certificate of compliance. An examination of the physical location must occur prior to the addition of the location on the provider’s certificate of compliance for center-based services. Inspection Procedures: For agencies seeking an IBHS license, OMHSAS Licensing Representatives will review the initial service description, the licensing application packet, and examine the provider’s physical location to assure the setting simulates a natural or normal setting.  For IBHS licensed agencies seeking to add center-based services, OMHSAS Licensing Representatives will provide specific guidance on the process of adding the center-based service onto the license.  Primary Benefit: Ensures that services are provided in an environment that allows the provider to observe the individual’s natural behaviors and provide services that will translate well into their everyday life.

Regulation: § 5240.2. Definitions. EBT—Evidence-based therapy — Behavioral health therapy that uses scientifically established behavioral health interventions and meets one of the following:      (i)    Categorized as effective by the Substance Abuse and Mental Health Services             Administration in the Evidence-Based Practice Resource Center.     (ii)   Categorized as Model or Model Plus in the Blueprints for Healthy Youth             Development registry.     (iii)  Categorized as well-established by the American Psychological Association’s             Society of Clinical Child and Adolescent Psychology.            (iv)   Rated as having positive effects by the Institute of Education Sciences’                     What Works Clearinghouse. Discussion: The following EBT service models are currently approved through DHS to be provided through the IBHS regulation: Multisystemic Therapy (MST)MST for problematic sexual behavior (MST-PSB)MST-psychFunctional Family Therapy (FFT)Parent-Child Interactive Therapy (PCIT) EBT service models provided through the IBHS regulation must be currently recognized by the body that governs the applicable EBT model. The following list shows EBT  governing bodies and the currently approved EBT service variations governed. MST Services (MST/MST-PSB/MST-psych)Functional Family Therapy, LLC (FFT)PCIT International (PCIT) Inspection Procedures: For agencies seeking an IBHS license, OMHSAS Licensing Representatives will review the service description and licensing application packet to determine if the provider provides EBT services, and if so, will provide approval. EBT services will be reviewed during initial and annual site visits to assure compliance to the EBT models. Primary Benefit: Ensures individuals receiving service have access to providers that have been determined to be evidence-based and are assured to meet fidelity to the model.

Regulation: § 5240.2. Definitions. Full-time equivalent—37.5 hours per week of staff time. Discussion: The Department interprets the regulatory definition of Full-time equivalency (FTE) to include time spent in both direct service provision and non-billable activities related to behavioral health services. When determining if an individual who provides IBHS services works a full-time equivalent, the IBHS provider should include all hours the individual is considered to be working for the IBHS provider. Inspection Procedures: OMHSAS Licensing Representatives will the program information form, and may review staff rosters, staff schedules, and other documentation as needed. Primary Benefit: Ensures a standardized definition of what is considered a full-time equivalent.

Regulation: § 5240.2. Definitions. Group services—Therapeutic interventions provided primarily in a group format through psychotherapy; structured activities, including ABA services; and community integration activities that address a child’s, youth’s or young adult’s identified treatment needs. Discussion: The certificate of compliance of IBHS licensed providers will identify the specific services in which they are licensed to provide; Individual, ABA, Group.  The Department interprets a group to be defined as two or more individuals, as outlined in the service description.  For IBHS agencies that provide Group services, all locations where Group services are provided must be included on the certificate of compliance as a service location. These service locations that appear on the certificate of compliance must be visited as outlined in “Part 1: An Introduction and Overview of the Regulatory Process” in the section titled, “Frequency of OMHSAS Inspections of Service Locations”. When IBHS agencies wish to add locations to provide Group services, they must contact the OMHSAS Licensing Representative for inclusion on the certificate of compliance before services may be provided at the location. Inspection Procedures: For agencies seeking an IBHS license, OMHSAS Licensing Representatives will review the initially submitted service description and licensing application packet to determine if the provider provides Group services. Service locations will be visited by OMHSAS Licensing Representatives as outlined in the “Frequency of OMHSAS Inspections of Service Locations” located in Part 1 of this Regulatory Compliance Guide. If an IBHS licensed provider wishes to add Group services to their certificate of compliance, OMHSAS Licensing Representatives will review an updated service description, examine the physical location for Group services, and provide additional guidance regarding the documentation needed for inclusion of the location on the license, as needed.  Primary Benefit: Ensures that individuals have an opportunity to receive services provided in the group setting as appropriate, and in a format as defined.

Regulation: § 5240.2. Definitions. Individual services—Intensive therapeutic interventions and supports that are used to reduce and manage identified therapeutic needs, increase coping strategies and support skill development to promote positive behaviors with the goal of stabilizing, maintaining or maximizing functioning of a child, youth or young adult in the home, school or other community setting. Discussion: The certificate of compliance of IBHS licensed providers will identify the specific services in which they are licensed to provide: Individual, ABA, Group, EBT.  The certificate of compliance will identify if the provider is licensed to provide Individual services.  Individual services can include, but are not limited to: behavioral consultation, mobile therapy, behavioral health technician services, and evidence-based therapy. If a provider seeking an IBHS license is not sure whether the services they provide fall under Individual services, the provider should contact their regional OMHSAS Field Office for assistance. Inspection Procedures: For agencies seeking an IBHS license, OMHSAS Licensing Representatives will review the initially submitted service description and licensing application packet to determine if the provider provides Individual services. For existing providers, OMHSAS Licensing Representatives will review individual chart records and staff records and may review the current service description and/or other documents to determine if the provider is properly licensed to provide Individual services. If an IBHS licensed provider wishes to add Individual services to their certificate of compliance, OMHSAS Licensing Representatives will review an updated service description. This would include adding an additional county or area of service. Primary Benefit: Ensures services identified as Individual services are provided under a standardized understanding of what constitutes an Individual service.

Regulation: § 5240.2. Definitions. Manual restraint—A physical hands-on technique that restricts the movement or function of a child, youth or young adult, or a portion of a child’s, youth’s or young adult’s body. A manual restraint does not include the use of hands-on assistance needed to enable a child, youth or young adult to achieve a goal or objective identified in an ITP. Discussion: The Department interprets the definition of manual restraint to be any hands-on technique that restricts movement and is not utilized to achieve a goal or objective in the ITP. This includes, but is not limited to, techniques to limit the imminent risk of harm to self or others and techniques to assist the individual away from the imminent risk of harm. All manual restraints must be conducted in accordance with § 5240.6(c)-(i) (relating to restrictive procedures). Inspection Procedures: OMHSAS Licensing Representatives will request all records of manual restraints conducted in the review period of the annual licensing visit, and may additionally review individual records, staff training, policies and procedures, and conduct interviews to determine compliance with this regulation. Primary Benefit: Ensures providers are aware that any hands-on technique that restricts movement and is not utilized as a part of the ITP is considered a manual restraint and should be carried out and documented as outlined in this regulation.

Regulation: § 5240.2. Definitions. Mechanical restraint—The use of a device attached or adjacent to a child’s, youth’s or young adult’s body that restricts freedom of movement or normal access to the child’s, youth’s or young adult’s body which cannot easily be removed by the child, youth or young adult. A mechanical restraint does not include the use of a seat belt during movement or transportation or a device prescribed by a licensed medical professional. Discussion: The Department suggests that agencies serving individuals who are prescribed a device that restricts freedom of movement should keep documentation in the individual record to verify the device was prescribed by a licensed medical professional (psychiatrists, physicians, and physician extenders), and include instruction on how the device should be used.  Inspection Procedures: OMHSAS Licensing Representatives will review staff training, policies and procedures, and may conduct interviews to determine compliance with this regulation Primary Benefit: Provides a standard definition of what is considered a mechanical restraint and allows for exceptions for seatbelts used during movement or transportation or devices prescribed by a licensed medical professional.

Regulation: § 5240.2. Definitions. Restrictive procedure—A practice that limits or restricts a child’s, youth’s or young adult’s freedom of movement, activity or function. Discussion: Not all restrictive procedures are restraints. Restrictive procedures may or may not be appropriate. Agencies should have policies and procedures outlining the use of restrictive procedures. If there is a question or concern about an individual’s treatment in regards to a restrictive procedure, the IBHS provider should reach out to their OMHSAS regional office. Inspection Procedures: OMHSAS Licensing Representatives will review staff training, policies and procedures, and may conduct interviews to determine compliance with this regulation.  Primary Benefit:  Provides a standard definition of what is considered a restrictive procedure.

Regulation: § 5240.2. Definitions. Seclusion—The involuntary confinement of a child, youth or young adult alone in a room or an area from which the child, youth or young adult is physically prevented from leaving. Discussion: The Department interprets seclusion to include any involuntary confinement alone in a room or area in which the child, youth or young adult is physically prevented from leaving.  Physical prevention may include a closed door, one or more person(s) blocking the exit, or any other means to prevent exiting the room or area. In order for a child, youth or young adult to not be considered alone, any staff member(s) present should not prevent the child from exiting the room or area. Inspection Procedures: OMHSAS Licensing Representatives will review individual records, staff trainings, policies and procedures, and may conduct interviews to determine compliance with this regulation. Primary Benefit: Ensures providers are informed of what constitutes seclusion, as this procedure is prohibited due to high possibility of emotional distress.

Regulation: § 5240.2. Definitions. Trauma-informed approach—An approach that recognizes the widespread impact of trauma including the signs and symptoms of trauma and potential paths for recovery by integrating knowledge about trauma into policies, procedures and practices that avoids re-traumatization. Discussion: The Department suggests all providers are at least trauma-aware and include a trauma-informed approach in their delivery of services. Information on a trauma-informed approach should be integrated into policies and procedures, and training as a best practice.  Trauma-aware refers to a provider becoming aware of trauma, the prevalence of trauma, and considers the potential impact of trauma on individuals receiving services and staff. Inspection Procedures: OMHSAS Licensing Representatives will review documentation that supports a trauma-informed approach. Primary Benefit: Ensures that children and families receive services in a trauma-informed environment. Ensures that signs and symptoms of trauma are addressed within treatment.

Regulation: § 5240.2. Definitions. Treatment team—Individuals involved in a child’s, youth’s or young adult’s treatment. Members of the treatment team may include the child, youth, young adult, parents, legal guardians, caregivers, teachers, individuals who provide services and any individual chosen by the child, youth, young adult or parents or legal guardians of the child or youth to be part of the treatment team. Discussion: The Department suggests that all members of the treatment team should have a collaborative working relationship and maintain communication in regards to the child’s, youth’s or young adult’s treatment. Children who are 14 and older should have an active role in treatment as outlined in Act 65 of 2020. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures outlining the composition of a treatment team, and individual chart records to assure compliance with this regulation. Primary Benefit: Ensures that a treatment team that includes individuals who are relevant in the individual’s treatment is defined and coordination is carried out with these members in supporting the best treatment of the child, youth, or young adult.

Regulation: § 5240.3. Provider eligibility. Except for IBHS agencies described in subsections (c)—(e), an IBHS provider shall obtain a license from the Department prior to beginning operations. Discussion: Agencies shall obtain a certificate of compliance prior to providing services that may fall under IBH. Inspection Procedures: OMHSAS regional Field Offices will review and approve application material and a certificate of compliance will be issued. Primary Benefit: Ensures all agencies that provide IBHS are licensed by the Department and meet the qualifications as set forth in the regulations.

Regulation: § 5240.3. Provider eligibility.            (f)  An IBHS provider shall meet the requirements in Chapter 20 (relating to licensure              or approval of facilities and agencies). Discussion: Title 55 Chapter 20 outlines licensure and approval requirements that are important for IBHS licensed agencies to understand. This chapter highlights important topics such as: application and reapplication, licensing fees, fire safety approval, civil rights compliance, the inspection process, plan of correction process, and the different types of certificates of compliance.  Additionally, § 20.34 (relating to access) outlines the requirements of the provider to provide access to the facility and records for announced and unannounced inspections. Questions on the interpretation and application of Chapter 20 requirements should be directed to the regional OMHSAS Field Office for agencies applying for IBHS licenses or the OMHSAS Licensing Representative for agencies who already hold an IBHS license. Inspection Procedures: For agencies seeking an IBHS license, OMHSAS Licensing Representatives will review the application packet. DHS Licensing Administration will review applications and reapplications and process licensing fees. OMHSAS Licensing Representatives will ensure that access to facility and records are provided in accordance with Chapter 20 requirements.  Primary Benefit: Ensures a standardized method to attain and retain a license to provide mental health services in the Commonwealth and ensures information necessary to conduct inspections is provided to the Department.

Regulation: § 5240.4. Organizational structure. An IBHS provider shall have an administrative director, clinical director and staff. Discussion: The Department interprets the regulation to mean that IBHS licensed providers should have a distinct administrative director, clinical director, and a staffing pattern that is sufficient to provide services to all members receiving services in the provider. However, as outlined in § 5240.11(c), an administrative director may also be a clinical director if the person meets the qualifications for both positions.  Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, the facility’s organizational chart, and staff qualifications and credentials (for example: transcripts, diplomas, resumes, licenses) to determine compliance with this regulation. Primary Benefit: Ensures that the IBHS provider has appropriate and qualified staff designated for specific roles and responsibilities that assure service standards are met.

Regulation: § 5240.4. Organizational structure. The organizational structure of the IBHS provider must be specified in an organizational chart, and the IBHS provider shall notify the Department within 30 days of a change in the organizational structure of the IBHS provider. Discussion: The Department suggests that the facility’s organizational chart should diagram how the provider is structured. It is recommended that it outline the roles, responsibilities, and relationships between staff within the organization. The organizational chart may depict the structure of the organization as a whole or be broken down by department or unit. Agencies shall notify the OMHSAS Licensing Representative of changes to the legal entity contacts and clinical and administrative directors. If a provider provides multiple levels of care, an organizational chart should distinguish IBHS as separate and distinct. The 30-day timeframe referenced in this section is interpreted by the Department to mean 30 calendar days and not 30 business days. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, the facility’s organizational chart, and may conduct staff interviews to determine compliance with the regulation. OMHSAS Licensing Representatives will review updated organizational charts when submitted by a licensed IBHS provider, and review staff qualifications and credentials. OMHSAS Licensing Representatives will review the organizational chart to determine if changes to the chart were reported to the Department within 30 calendar days of the change. Primary Benefit: Organizational charts ensure that staff roles within the provider are clearly defined. Notifying the Department of major changes helps to ensure that the Department is kept informed of organizational or service modifications.

Regulation: § 5240.5. Service description. (a)  As part of the initial licensing application, the IBHS provider shall submit to the       Department for review and approval a written description of services to be       provided that includes the following:               (1)   Identification and description of each service offered by the IBHS provider.              (2)   Identification of the target population served by each service, including age                       range and presenting issues, which may include specific diagnoses.              (3)   The days and hours each service is available.      (4)   Identification of the counties where the IBHS provider provides each service.              (5)   Description of admission criteria.              (6)   Description of discharge criteria.              (7)   Description of exclusionary criteria.      (8)   Staffing ratios for each service offered by the IBHS provider.              (9)   Treatment modalities.              (10)  Locations where services are offered.              (11)  Maximum number of children, youth or young adults served at the same                       time through group services at a community setting or a community like                        setting. Discussion: Service descriptions are sent to OMHSAS for review as part of the license application process. It is recommended that a provider submit one service description that includes each service the provider will provide. It is not necessary to have an approved service description before a provider submits the packet for an initial certificate of compliance. In addition to the topics to be included as outlined above, the provider should include: The address of the facility to be the main address on the license, and each additional service location (service locations may be facilities where Group services or center-based services are provided). Additionally, letters of acknowledgment/support from each county in which services will be provided should be sent to OMHSAS. The Department interprets the requirements to document the locations the services are provided, in § 5240.5(a)(10), to mean at a minimum: the full address of the facility to be identified as the main address on the license and each additional service location. Service locations are facilities where Group services, ABA services provided in a community like setting, and provider centers where approved center-based one-on-one services are provided. In order for an IBHS provider that provides Group services to verify they meet the requirements of § 5240.5(a)(11), the provider should track the attendance for each Group service. If an IBHS provider has multiple licenses, for example, because they serve individuals across two or more OMHSAS Field Office regions, the provider should coordinate with OMHSAS Licensing Representatives from each regional OMHSAS Field Offices when submitting the initial service description or when making changes that will affect the service description in multiple regions. If the provider wishes to provide center-based one-on-one services, OMHSAS Licensing Representatives will review the service description to determine requirements of OMHSAS-21-02 Provision of One-to-One Intensive Behavioral Health Services in a Licensed Location are met.  Additionally, per § 5240.61(a)(iv), compliance with the provider’s approved service description should be part of an annual review of the quality, timeliness, and appropriateness of services. Inspection Procedures: OMHSAS Licensing Representatives will review the service description during the application process, and during initial and annual site visits. OMHSAS Licensing Representatives will review provider documentation to assure compliance with this regulation. Primary Benefit: Ensures that an IBHS provider has a written plan that outlines important aspects of service provisions, that includes but is not limited to: the services the provider offers, who is appropriate for the services provided, as well as how and where the services will be provided.

Regulation: § 5240.5. Service description. Prior to the IBHS provider changing its services or if the information in the service description is otherwise no longer accurate, the IBHS provider shall submit an updated service description to the Department for review and approval. Discussion:  Any changes or additions enacted to an approved service description will require an updated service description to be approved. This includes, but is not limited to change or addition of locations where services are offered and change or addition of services provided. The Department suggests that when a provider wants to add a new county for provision of services, an updated service descriptions should include any additional counties where services will be provided. A county letter of support is also required if the IBHS provider is adding a service location to their license. It is recommended that service descriptions contain generalized information so that minor changes will not require a change to the service description. For example, instead of citing “DSM-V”, it could state “the most recent version of the DSM” and instead of listing the name of staff member it could list the title of the position. Title 55 Chapter § 20.58 requires notification of a change in the legal entity, name, location, and profit or nonprofit status of the facility or provider to be reported at least 30 days in advance to the Department. Any such changes should include a change in the service description. Inspection Procedures: When OMHSAS Licensing Representatives receive updated service descriptions to review, they will coordinate with the IBHS provider to request any documents needed to complete the approval. During licensing inspections or upon an ad hoc request, OMHSAS Licensing Representatives may review provider documentation to assure any service or structural change does not conflict with the provider’s approved service description.  Primary Benefit: Ensures that OMHSAS and the Department is aware of any changes that have been made to the organizational structure and/or services provided by the provider.

Regulation: § 5240.6. Restrictive procedures. The following restrictive procedures are prohibited:        (1)  Seclusion.        (2)  Aversive conditioning.               (3)  Pressure-point technique.               (4)  Chemical restraint.               (5)  Mechanical restraint.               (6)  A restrictive procedure that is not the least restrictive procedure.               (7)  A restrictive procedure that does not maintain a child’s, youth’s or young                      adult’s welfare and dignity.   (8)  A restrictive procedure that limits a child’s, youth’s or young adult’s access           to food, drink or toilet. Discussion: Additional information on seclusion, mechanical restraint and restrictive procedures can be found 5240.2 Definitions section. Inspection Procedures: OMHSAS Licensing Representatives will review individual case records and incident reports, policies and procedures, and may conduct staff interviews to assure compliance with this regulation.  Primary Benefit: Ensures protection of individual rights and safety within an IBHS provider.

Regulation: § 5240.6. Restrictive procedures. An IBHS provider that uses restrictive procedures shall have written policies and procedures that identify the specific restrictive procedures that may be used and when such restrictive procedures may be used. Discussion: Policies and procedures are required for any provider that uses restrictive procedures. Some IBHS agencies may decide not to allow restrictive procedures unless it is an emergency situation in order to ensure the safety of the child or others. Any such IBHS provider should still have written policies and procedures that outline a definition of what constitutes an emergency event, allowable restrictive procedures for those events, and training of staff to provide appropriate restrictive procedures when those events occur. Inspection Procedures: OMHSAS Licensing Representatives will review the provider’s service description and policies and procedures at the time of application and as updates are submitted. OMHSAS Licensing Representatives will review individual case records and incident reports, and may conduct staff interviews to assure compliance with this regulation. Primary Benefit: Ensures that the IBHS provider has considered situations that would require the use of restrictive procedures, and have outlined steps to assure the individual’s safety and rights are maintained. This regulation also gives OMHSAS a mechanism to provide oversight in the use of restrictive procedures.

Regulation: § 5240.6. Restrictive procedures. A manual restraint shall only be used in an emergency situation to prevent self-injury or injury to others by a child, youth or young adult and only after:          (1)  Every attempt has been made to anticipate and de-escalate the behavior.    (2)  Less intrusive techniques and resources appropriate to the behavior have been           tried and failed. Discussion: Any time a physical hands-on technique that restricts the movement or function of an individual receiving IBHS services is used, it is considered a manual restraint. This is inclusive of transportation methods where freedom of movement is limited by a hands-on technique, unless it is a hands-on assistance needed to enable the individual to achieve a goal or objective identified in the ITP. Attempts to anticipate and de-escalate the behavior and less intrusive techniques and resources should be tried and failed before a manual restraint is ever initiated, even if in the past such attempts had failed. Similarly, the less intrusive techniques and resources appropriate to the behavior should be tried and failed before a manual restraint is ever initiated, even if in the past such attempts had failed. For each time a manual restraint is initiated, these attempts should be documented in the individual’s records as outlined in  § 5240.41(a)(12)(ii).  Inspection Procedures: OMHSAS Licensing Representatives will review the provider’s policies and procedures, individual case records, incident reports, and may conduct staff interviews or review video footage to assure compliance with this regulation. Primary Benefit: Ensures that manual restraints are only used as a last resort in an emergency situation after staff members have tried to de-escalate and have tried less intrusive means and techniques before initiation of restraint.

Regulation: § 5240.6. Restrictive procedures.      (d) A manual restraint may not:Apply pressure or weight on a child’s, youth’s or young adult’s respiratory system.Use a prone position. Discussion: Techniques that have not been approved through a DHS-approved restrictive procedures training should not be utilized during a manual restraint. Manual restraints should never be conducted in a manner that may restrict breathing.  Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, individual case records, incident reports, and may conduct staff interviews to assure compliance with this regulation. Primary Benefit: Ensures that the IBHS provider does not utilize methods of manual restraint that have been found to be dangerous for the individual receiving services.

Regulation: § 5240.6. Restrictive procedures.      (e) The position of the manual restraint or the staff person applying a manual            restraint shall be changed at least every 10 minutes during the application of the            manual restraint. Discussion: When there is sufficiently trained and capable staff to allow a change in the staff member performing the manual restraint, it is recommended a staff change should be prioritized over a change to the position of the restraint. When possible, a change in both the staff person performing the restraint and the position of the restraint is ideal. Each ten-minute interval and the corresponding change in staff performing restraint or position of the restraint should be documented in the individual’s records as outlined in § 5240.41.(a)(12)(iv) e.g. the name and training of the staff person who used the manual restraint. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, individual case records, incident reports, and may conduct staff interviews to assure compliance with this regulation. Primary Benefit: Ensures that the child, youth or young adult in a manual restraint is not held in the same position for more than 10 minutes, minimizing the risk of long-term side effects of the restraint. A change in the staff person allows further protection to the child, youth and young adult as well as the staff member, by limiting staff fatigue.

Regulation: § 5240.6. Restrictive procedures.      (f) A trained individual who is not applying the manual restraint shall observe and          document the physical and emotional condition of the child, youth or young adult at          least every 10 minutes during the application of the manual restraint.Discussion: The Department interprets a trained individual as an individual trained as outlined in § 5240.6(k). It is recommended that documentation should be included in the individual’s record as outlined in § 5240.41.(a)(12)(iv) e.g. the name and training of the staff person who used the manual restraint. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, individual case records and incident reports, staff training records, and may conduct staff interviews to assure compliance with this regulation. Primary Benefit: Ensures that the staff member is observing and documenting the physical and emotional condition of the individual at regular intervals to assure required changes in position and/or staff are implemented and to account for the individual’s safety and welfare throughout the duration of the manual restraint.

Regulation: § 5240.6. Restrictive procedures.      (g) A manual restraint shall be discontinued when the child, youth or young adult is no           longer an imminent danger to self or others.Discussion: Staff should observe the individual’s behaviors and emotional response to the manual restraint to assess when the restraint is no longer needed. § 5240.41(a)(12) (v) requires the duration of the manual restraint be documented as part of the manual restraint documentation in the individual’s record. The Department suggests that IBHS providers document these behaviors and responses to explain how the duration of the manual restraint was determined. Inspection Procedures: OMHSAS Licensing Representatives will review the provider’s service description and policies and procedures at the time of application and as updates are submitted. OMHSAS Licensing Representatives will review individual case records and incident reports, and may conduct staff interviews to assure compliance with this regulation. Primary Benefit: Ensures that manual restraints are not carried on longer than is needed to prevent imminent danger of the individual harming self or others.

Regulation: § 5240.6. Restrictive procedures.      (h)  Within 24 hours of using a manual restraint on a child, youth or young adult, an            IBHS provider shall notify the treatment team.Discussion: Treatment team is defined in § 5240.2 (relating to definitions). Treatment team should include individuals involved in the treatment. Per this definition, members of the treatment team may include the individual, parents, legal guardians, caregivers, teachers, individuals who provide services, and any individual chosen by the child, youth, young adult or parents or legal guardians of the child or youth to be part of the treatment team. All members of the treatment team should be notified within 24 hours of the manual restraint. IBHS agencies should have policies and procedures that outline the process of determining the members of the treatment team as well as the process to inform all treatment team members when a manual restraint is utilized. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, individual case records and incident reports, any documentation that the IBHS provider uses to track manual restraints and may conduct staff interviews to assure compliance with this regulation. Primary Benefit: Ensures communication among the treatment team and continuity of care.

Regulation: § 5240.6. Restrictive procedures.      (i)  An IBHS provider shall document the use of a manual restraint in the child’s,           youth’s or young adult’s individual record in accordance with §  5240.41(a)(12)           (relating to individual records).Discussion: The Department suggests that IBHS agencies create a standardized form that will ensure all required elements are documented. Manual restraint documentation should describe how the use of the manual restraint was carried out in accordance with §  5240.6 and should record the following: The specific behavior addressed.The less intrusive methods of intervention used to address the behavior prior to initiating the manual restraint used.The specific manual restraint used.The name and training of the staff person who used the manual restraint.The duration of the manual restraint.The name of the trained individual who observed the child, youth or young adult during the application of the manual restraint.The child’s, youth’s or young adult’s condition following the manual restraint.The date and time the manual restraint was used.The date and time the treatment team was notified of the use of a manual restraint and the members of the treatment team who were notified. Inspection Procedures: OMHSAS Licensing Representatives will review individual case records and incident reports, and may conduct staff interviews to assure compliance with this regulation. Primary Benefit: Ensures that manual restraints are fully documented in the individual’s records in a standardized format with required information as outlined in regulation.

Regulation: § 5240.6. Restrictive procedures.      (j)  An IBHS provider that uses manual restraints shall have policies and procedures for           the use of manual restraints that shall include the following:          (1)   Appropriate use of the manual restraint, including prohibitions on the use of a                  manual restraint.          (2)   Required use of less intrusive techniques and resources appropriate to the                   behavior prior to the use of a manual restraint.          (3)   Immediate discontinuation of the manual restraint when the child, youth or                       young adult is no longer an imminent danger to self or others.          (4)   The staff who may authorize the use of a manual restraint.          (5)   How the use of a manual restraint will be monitored.Discussion: Policies and procedures are required for any provider that uses manual restraints. Some IBHS agencies may decide not to allow manual restraints unless it is an emergency situation, to ensure the safety of the child or others. Any such IBHS provider should have written policies and procedures that outline, at a minimum: a definition of what constitutes an emergency event, manual restraint techniques that may be appropriate in response to an emergency event, training of staff to provide appropriate restrictive procedure in an emergency event, the procedure to notify all members of the individual’s treatment team of the manual restraint, the procedure to document the manual restraint, and how families are trained regarding manual restraints if the provider decides to provide such training.If the IBHS provider prohibits manual restraints in all situations, that provider should nevertheless have a policy outlining the procedure will never be utilized. The policy should outline what will occur in a crisis or emergency situation and who will be responsible to take any needed actions. The policy should also include how parents are to be notified of the procedures outlined in the policy. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, individual case records and incident reports, any documentation that the IBHS provider uses to track manual restraints and may conduct staff interviews or review video footage to assure any manual restraints were performed according to the provider’s policies and procedures and regulatory requirements. Primary Benefit: Ensures that the provider has considered provider-specific utilization of manual restraints and has created standardized procedures to dictate the utilization of manual restraints. Standardized policies and procedures that outline the use of manual restraints will limit inappropriate and dangerous treatment to individuals receiving services.

Regulation: § 5240.6. Restrictive procedures.      (k) An IBHS provider shall require yearly training that is approved by the Department     for staff who administer a restrictive procedure that includes the following:           (1)  De-escalation techniques and strategies.           (2)  Proper use of the restrictive procedure, including what is appropriate for the                  age and weight of a child, youth or young adult.           (3)  Demonstrated experience in the proper use of the restrictive procedure,                   including practice on other staff.           (4)  A testing process to demonstrate the ability to properly apply the restrictive                  procedure.Discussion: The Department considers “yearly” in the context of this section of the regulation to mean roughly 365 days. A provider may determine whether their training calendar will be identified as a “calendar year”, “fiscal year”, or run from the date of hire.  Once determined (and identified in training policy) training records will be reviewed for compliance with the provider’s identified method. A list of approved training resources that do not require additional Department approval, an outline of the process for Departmental approval of trainings, and the training approval request form is available on the Pennsylvania DHS IBHS website. It is recommended that all staff be trained in restrictive procedures in the event that they are required to use a restrictive procedure, even when the restrictive procedure occurs during a non-routine emergency event. IBHS provider staff should be trained on the importance of reviewing the physical assessment to be aware of any physical history/preexisting condition of the individual served that should be considered when administering a restraint. Inspection Procedures: OMHSAS Licensing Representatives will review training documentation and personnel files, individual records and incident reports, any documentation that the IBHS provider uses to track manual restraints and may conduct staff interviews to assess compliance with this regulation. Primary Benefit: Ensures that staff members who participate in restrictive procedures are trained annually to assure approved techniques and procedures are continuously utilized in an appropriate manner.

Regulation: § 5240.6. Restrictive procedures. (l)  An IBHS provider shall keep a record of each staff person’s training in the use of     restrictive procedures in each staff person’s personnel file in accordance with §      5240.42(b)(2) (relating to provider records).Discussion: The Department suggests that all staff be trained in restrictive procedures in the event that they are required to use a restrictive procedure, even when the restrictive procedure occurs during a non-routine emergency event. IBHS provider staff should be trained on the importance of reviewing the physical assessment to be aware of any physical history/preexisting condition of the individual served that should be considered when administering a restraint.It is recommended that the provider keeps a record of training in each staff member’s personnel files instead of a file devoted to training for the entire IBHS provider because training files must be retained for at least 4 years after staff member is no longer employed with the provider per § 5240.42(b)(2). Inspection Procedures: OMHSAS Licensing Representatives will review training documentation and personnel files to assess compliance with this regulation. Primary Benefit: Ensures a record that verifies that staff members have been trained is easily accessible.

Regulation: § 5240.6. Restrictive procedures. (m)  An IBHS provider that provides training to parents, legal guardians or caregivers        on the use of restrictive procedures that are included in the child’s, youth’s or        young adult’s ITP shall use trainings approved by the Department and have        policies and procedures that address training parents, legal guardians or        caregivers on the use of restrictive procedures.Discussion: The Department suggests that training provided to parents should include an explanation on the process the IBHS provider will use to notify all treatment team members in the event a manual restraint is used, and an explanation of the process used to notify the parents when restrictive procedures are used.A list of approved training resources that do not require additional Department approval, an outline of the process for Departmental approval of trainings, and the training approval request form are available on the Pennsylvania DHS IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures and training documents to ensure compliance with the regulation. Primary Benefit: Ensures that trainings provided to parents/legal guardians/caregivers regarding restrictive procedures included in the ITP meet Departmental standards and that the IBHS provider has standardized policies dictating how parents/legal guardians/caregivers are trained in this subject.

Regulation: § 5240.7. Coordination of services. An IBHS provider shall have written agreements to coordinate services with other service providers, including the following:   (1)  Psychiatric inpatient facilities.   (2)  Partial hospitalization providers.   (3)  Psychiatric outpatient clinics.   (4)  Crisis intervention providers.   (5)  Mental health and intellectual or developmental disability case management          providers.Discussion: The Department suggests IBHS agencies review and re-negotiate all agreements on a timely basis not to exceed 5 years to ensure agreements are current and are not held with other service providers who are no longer in operation or no longer providing the services that were discussed at the time of the original agreement.When an IBHS provider attempts to enact a written agreement with another service provider but receives no response, the provider may provide the OMHSAS Licensing Representative documentation to verify that an attempt was made. The IBHS provider should continue additional attempts with the service provider or find other service providers in the area who provide the same service.In order to fulfill the requirements of this section of the regulation, the IBHS provider should enter into a written agreement with at least one service provider from each category. However, OMHSAS suggests that IBHS agencies enter into more than one in each category in order to allow provider choice when referrals are made. Inspection Procedures: OMHSAS Licensing Representatives will review written agreements during initial and annual licensing review and ensure agreements cover all required levels of care to determine compliance with this section of the regulation. Primary Benefit: To create an understanding between the IBHS provider and other service providers, to help improve continuity of care planning, and to inform staff of the current resources in the area where referrals may be made.

Regulation: § 5240.7. Coordination of services.An IBHS provider shall update the written agreements with other service providers at least every 5 years.Discussion: The Department interprets compliance with this section of the regulation to be demonstrated by an IBHS provider ensuring that written agreements with other service providers are signed and dated.  Inspection Procedures: OMHSAS Licensing Representatives will review written agreements to ensure all have been executed no more than 5 years prior to the review. Primary Benefit: Ensures a standardized timeframe is utilized to assure agreements made with outside agencies are current and functioning.

Regulation: § 5240.7. Coordination of services. An IBHS provider shall have a list of community resources that provide behavioral health services that is available upon request by a parent, legal guardian, or caregiver of a child or a youth, or a youth or young adult receiving services that includes the following:   (1)  The name of the provider or organization.   (2)  Description of the services provided.   (3)  Address and phone number of the provider or organization.Discussion: OMHSAS suggests that the list of community resources that provide behavioral health should at a minimum, include all of the levels of care in which the provider is required to enter into a written agreement under 5240.7 Coordination of Services. These services include psychiatric inpatient facilities, partial hospitalization providers, psychiatric outpatient clinics, crisis intervention providers, and mental health and intellectual or developmental disability case management providers. In an effort to best serve the individuals and families receiving IBHS services, agencies may include non-behavioral health related services that address the individual and family’s social determinants of health.If IBHS agencies utilize a list created outside of their provider, it is their responsibility to verify at least annually the accuracy of the information found in the list. This verification should be documented with the date it was performed.  Inspection Procedures: OMHSAS Licensing Representatives will review the community resource list during initial licensing inspection and annually to ensure required information is captured. Primary Benefit: To ensure agencies have community information that is easily accessible for their clients and families.

Regulation: § 5240.7. Coordination of services. An IBHS provider shall update the community resource list annually.Discussion: Due to the requirement for the community resource list to be updated annually, the Department suggests that the date of the most recent update should be included on the document. A provider staff member should annually review the list and verify that the identified agencies still provide the referenced services, and that the address and phone numbers are valid. OMHSAS suggests the provider should have a policy and procedure to outline the staff position whose responsibility it is to annually review this list and outline the process in which the review is conducted.If IBHS agencies utilize a list created outside of their provider, it is their responsibility to verify at least annual the accuracy of the information found in the list. This verification should be documented with the date it was performed.  Inspection Procedures: OMHSAS Licensing Representatives will review the community resource list during annual licensing inspections to assure the list has been updated annually. Primary Benefit: To ensure community resource information is updated regularly.

Regulation: § 5240.7. Coordination of services. An IBHS provider shall have a written referral process for children, youth and young adults whose therapeutic needs cannot be served by the provider. The IBHS provider shall document in its records referrals made for a child, youth or young adult the IBHS provider could not serve.Discussion: The Department suggests that the written referral process should address all circumstances where a referral may be required. This includes any initial referrals where it is determined the child, youth, or young adult has needs that cannot be served by the provider, and situations where the child can no longer be served by the provider. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures that outline the referral process, individual records, and may conduct interviews to determine compliance with this section of the regulation. Primary Benefit: To ensure those who cannot be served by the provider have the opportunity to get services elsewhere.

STAFFING

Regulation: § 5240.11.  Staff requirements.(a)  An IBHS provider shall have an administrative director and a clinical director.Discussion: OMHSAS suggests that IBHS agencies notify their assigned OMHSAS Licensing Representative in advance of changing an administrative or clinical director, because an IBHS provider operating with unqualified directors may jeopardize the health and safety of the individuals served. This notification will allow the OMHSAS Licensing Representative time to verify qualification requirements are met prior to the change.   Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, organizational charts, staff qualification documents, and client records to determine compliance with this section of the regulation. Primary Benefit: To ensure there are sufficient staff who are responsible for clinical and administrative oversight of the IBHS provider.

Regulation: § 5240.11. Staff requirements.(b)  An administrative director’s responsibilities shall include the following:   (1)  The overall daily management of the provider.   (2)  Ensuring that staff schedules meet the needs of the children, youth and young adults served and accommodate their parents’, legal guardians’ or caregivers’ schedules.   (3)  Ensuring compliance with staff qualifications and training requirements.   (4)  Monitoring the IBHS provider’s compliance with this chapter.   (5)  Developing and monitoring the quality improvement plan for the IBHS          provider.   (6)  Supervising staff who do not provide IBHS.Discussion: The Department interprets the regulation to mean that elements of the required responsibilities of the administrative director may be delegated but it is the administrative director’s overall obligation to assure they are all successfully met. Inspection Procedures: OMHSAS Licensing Representatives will review job description, organizational charts, and may conduct interviews with staff to determine compliance with this section of the regulation. Primary Benefit: To ensure all aspects of provider administration are overseen.

Regulation: § 5240.11. Staff requirements.(c)  An administrative director may also be a clinical director if the person meets       the qualifications for both positions.Discussion: In order for an provider to employ one staff member to provide both administrative and clinical direction, the Department suggests that the provider should consider its own size and structure, the complexity of services provided, and then determine whether it is feasible for one person to successfully carry out the duties of both roles.  Inspection Procedures: OMHSAS Licensing Representatives will review job descriptions, organizational charts, and may conduct interviews with staff to determine that the duties associated with both the administrative director and clinical director are met. Primary Benefit: To allow flexibility for an provider based on individual staffing abilities and needs.

Regulation: § 5240.11. Staff requirements.(d)  A clinical director’s responsibilities shall include the following:   (1)  Ensuring that staff who provide IBHS are supervised in accordance with this          chapter.   (2)  Maintaining clinical oversight of IBHS provided.   (3)  Ensuring staff who provide IBHS have access to supervisory staff during the           hours that IBHS are provided, including evenings and weekends.   (4)  Completing and documenting a clinical record review for quality of the IBHS          provided and compliance with this chapter and documenting the outcomes          of the review quarterly.   (5)  Ensuring that training for staff is being provided as required by this          chapter.Discussion: The requirement outlined in § 5240.11(d)(4) does not require a quarterly review of every clinical record. Instead, it requires the completion of a clinical record review of a sample of charts and documenting the outcome of the review. If the record review required for all charts, outlined in § 5240.41(b)(3), is conducted by the clinical director, separate reviews are not required to meet both regulatory requirements. It is recommended that the documentation of the outcomes of the review be included in the analysis of findings in the annual quality improvement report, which is outlined in § 5240.61. Inspection Procedures: OMHSAS Licensing Representatives will review job descriptions, organizational charts, individual records, and documentation of quarterly reviews, and may conduct interviews with staff to determine that the duties are being met. Primary Benefit: To ensure oversite of all aspects of clinical provider direction.

Regulation: § 5240.11. Staff requirements.(e)  An IBHS provider shall employ a sufficient number of qualified staff to comply with the administrative oversight, clinical supervision and monitoring requirements of this chapter.Discussion: The Department suggests that an IBHS provider should consider the size and structure of the provider, and the complexity of services provided to determine the sufficient number of staff.  Inspection Procedures: OMHSAS Licensing Representatives will review individual records, supervisions and training documents, and QI documents and annual reports to determine all aspects of clinical/administrative duties/responsibilities are met. Primary Benefit: To ensure the provider employs sufficient and qualified staff  to meet all oversight, supervision and monitoring requirements of the regulation.

Regulation: § 5240.11. Staff requirements.(f)  An IBHS provider shall employ a sufficient number of qualified staff to provide the maximum number of service hours identified in the written order and the ITP for each child, youth or young adult admitted to services.Discussion: The Department interprets this section of the regulation to mean that an IBHS provider should have a sufficient number of qualified staff to appropriately serve the clients that are enrolled in the provider at any given time. If any provider does not have the staff needed to serve a child, youth, or young adult, they should provide a list of agencies that are able to provide the medically necessary services. It is also recommended that a provider has a way to document whether a family chooses to stay and wait for services if there is not currently a sufficient number of staff to provide any or all of the hours indicated in the written order. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, client charts including written orders and ITPs, and staff schedules if hours are in question, to determine compliance with the regulation. Primary Benefit: To ensure children receive medically necessary services at the frequency in which they are prescribed in the written order and recommended in the ITP.

Regulation: § 5240.12. Staff qualifications.(a)  An administrative director of an IBHS provider shall meet one of the following:   (1)  The qualifications for a clinical director in subsection (b).   (2)  Have a bachelor’s degree in psychology, social work, counseling, education, human services, public administration, business administration or related field from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or have an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.Discussion:  An individual can serve as the administrative director of a provider that provides Individual services and/or ABA services and/or Group services as long as they are able to perform all tasks as outlined in § 5240.11(b) and meet the requirements outlined in this section and the respective qualification requirements of the ABA and/or Group services. § 5240.81(a) outlines qualification requirements of an administrative director that differ from requirements outlined in this section.Agencies are encouraged to search the United States Department of Education and/or the Council for Higher Education Accreditation (CHEA) websites to verify the college or university is accredited. Even though a college may sound familiar, diploma mills have been known to use familiar colleges by changing the name slightly so that it appears familiar. There are not only fake colleges but fake accreditation counsels, therefore an provider may need to verify the accrediting provider through one of the referenced provider websites. It should be noted that the Department of Education does not keep historical information on its website. In the case of Pennsylvania colleges that have gone from State Colleges to Universities, the State college information is not kept in the database.It is a recommended best practice to verify a person’s education through college transcripts. Transcripts are sent directly to a hiring provider and not the individual and contain a seal as well as the accrediting provider name. College diplomas may be forged easier than transcripts. Transcripts also provide course names that assist in verifying the number of hours in a particular curriculum.  Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, job descriptions, credentials, educational transcripts/degree and trainings, and may search the USDE or CHEA website to determine compliance with this section of the regulation. Primary Benefit: To ensure that only qualified staff are filling this role.

Regulation: § 5240.12. Staff qualifications.(b)  A clinical director of an IBHS provider shall have a minimum of 1 year of full      time postgraduate experience in the provision of mental health direct services      to children, youth or young adults and meet one of the following:   (1)  Be licensed in this Commonwealth as a physician practicing psychiatry, psychologist, professional counselor, marriage and family therapist, certified registered nurse practitioner with a mental health certification or clinical social worker.   (2)  Be licensed in this Commonwealth as a behavior specialist and have a graduate degree that required a clinical or mental health direct service practicum from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or have an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.   (3)  Be licensed in this Commonwealth as a social worker and have a graduate degree that required a clinical or mental health direct service practicum from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or have an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.   (4)  Be licensed in this Commonwealth as a professional with a scope of practice that includes overseeing the provision of IBHS and have a graduate degree that required a clinical or mental health direct service practicum from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or have an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency. Discussion:  An individual can serve as the clinical director of a provider that provides Individual services and/or ABA services and/or Group services as long as they are able to perform all tasks as outlined in § 5240.11(d) and meet the requirements outlined in this section and the respective qualification requirements of the ABA or Group services. § 5240.81(b) outlines the qualification requirements of a clinical director that differ from the requirements outlined in this section. In regards to qualification requirements for a certified registered nurse practitioner with a mental health certification,  outlined in § 5240.81(b)(1) above, OMHSAS will accept the following certifications at this time and will consider other certifications based upon a review of the qualifications and experience on a case by case basis. Certified Registered Nurse Practitioner Certifications      Pennsylvania Department of State approved certifications:Adult Psych Mental HealthFamily Psychiatric Mental HealthPsychiatric Mental Health      National Certifications in Psychiatric-Mental Health issued by:• The American Nurses Credentialing Center (ANCC)      Completion of a psychiatric-mental health provider accredited by:• The Commission on Collegiate Nursing Education (CCNE)• The Accreditation Commission for Education in Nursing (ACEN)• The National League for Nursing Accrediting Commission (NLNAC) Pediatric Nursing Certification Board certification:• Pediatric Primary Care Mental Health Specialist CertificationAgencies are encouraged to search the United States Department of Education and/or the Council for Higher Education Accreditation websites to verify the college or university is accredited. Even though a college may sound familiar, diploma mills have been known to use familiar colleges by changing the name slightly so that it appears familiar. There are not only fake colleges but fake accreditation counsels, therefore an provider may need to verify the accrediting provider through one of the referenced provider websites. It should be noted that the Department of Education does not keep historical information on its website. In the case of Pennsylvania colleges that have gone from State Colleges to Universities, the State college information is not kept in the database.It is a recommended best practice to verify a person’s education through college transcripts. Transcripts are sent directly to a hiring provider and not the individual and contain a seal as well as the accrediting provider name. College diplomas may be forged easier than transcripts. Transcripts also provide course names which assist in verifying number of hours in a particular curriculum. Clinical practicum and clinical internship can mean the same thing, depending on the provider. Documentation in the form of an official transcript is required to verify. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, job descriptions, credentials, educational transcripts/degree and trainings, and may search the USDE or CHEA website to determine compliance with this section of the regulation. Primary Benefit: To ensure that only qualified staff are filling this role and that they meet regulatory requirements.

Regulation: § 5240.12. Staff qualifications.(c)  This section does not apply to ABA services.Discussion: ABA has additional requirements for staff qualifications that are specific to that service. Inspection Procedures: OMHSAS Licensing Representatives will review ABA documents as outlined in the ABA qualification portion of the regulation. Primary Benefit: To ensure qualified staff are filling this role.

Regulation: § 5240.13. Staff training plan.(a)  An IBHS provider shall develop and implement a written plan to ensure initial   and annual training requirements are met that includes the following:   (1)  A written individual training plan that is:     (i)   Updated annually for each staff person.     (ii)   Based upon the staff person’s educational level, experience, current job        functions and performance reviews.     (iii)  Appropriate to the staff person’s skill level.   (2)  An overall plan to ensure that staff receive training in accordance with this chapter and in a manner that is consistent with the policies and procedures of the IBHS provider.   (3)  An annual review and update of the IBHS provider training plan based on service outcomes and staff performance evaluations.Discussion: Agencies are required to have a training plan for each staff person that is based on each staff person’s educational level, experience, current job functions and performance reviews. Inspection Procedures: OMHSAS Licensing Representatives will review the overall provider training plan and individual training plans at the initial licensing review and annually. Following the initial licensing review, subsequent reviews will incorporate a review of all new staff and 10% of existing staff training plans. Primary Benefit: To ensure staff members have initial and ongoing training plans that are tailored to their individualized training needs, and to improve upon quality of care.

Regulation: § 5240.13. Staff training plan. (b)  An IBHS provider shall keep documentation of completion of initial and annual training requirements in each staff person’s personnel file in accordance with §  5240.42(b)(2) (relating to provider records).Discussion: In addition to keeping an individualized training plan for each staff member, the provider should maintain training records for each staff member. Training records may be kept in a provider-wide training file, but to meet this requirement of the regulation training documentation should also be kept separately in the individual staff person’s personnel file. Inspection Procedures: OMHSAS Licensing Representatives will review the overall provider training plan and individual training plans at the initial licensing review and annually. Following the initial licensing review, subsequent reviews will incorporate a review of all new staff and 10% of existing staff training plans. Primary Benefit: To ensure agencies have on-going training for all staff and that it is documented.

Regulation: § 5240.13. Staff training plan. (c)  An IBHS provider shall accept documentation of completion of initial or annual training requirements from a college, university, National training organization, training entity accepted by a professional licensing organization or the Department. Discussion: Training that may be used for initial and annual training requirements must meet the approval criteria outlined by the Department. A training approved by the Department may be approved for more than one content area.  The previous will be listed on the training approval letter.  Annual training hours do not necessarily have to meet a specific content area.  The annual training must meet the required number of hours outlined in the regulation and in the needs identified in individual training plan.    Inspection Procedures: OMHSAS Licensing Representatives will review transcripts, training certificates, or other verification of college courses, and may review DHS training approval letters to determine compliance with this section of the regulation. Primary Benefit: To allow agencies to accept documented training accepted by a professional licensing organization or the Department to avoid unnecessary duplicative training hours.

Regulation: § 5240.13. Staff training plan. (d)  An IBHS provider may choose to not require a staff person to complete additional training if the staff person has completed the required initial or annual training while working for another IBHS provider.Discussion: It is the responsibility of the IBHS provider who accepts initial or annual training completed while a staff member worked for another IBHS provider to review the training and ensure it meets the staff member’s current training requirements and is within the annual timeframe of the training requirement it will be counted towards. This should be documented in the staff member’s personnel record as required in § 5240.13(b). Inspection Procedures: OMHSAS Licensing Representatives will review RBT Task list trainings, training certificates, and other documentation gathered by provider as verification that a staff member has already completed required IBHS training as outlined in the regulation to determine compliance with this section of the regulation. Primary Benefit: To allow agencies to accept documented training that a staff member received while working at another IBHS provider to avoid unnecessary duplicative training hours.

Regulation: § 5240.13. Staff training plan. (e)  An IBHS provider shall keep records of initial and annual trainings that it provides to staff that includes documentation of the following:   (1)  The date, time and location of the training.   (2)  The name of the person who conducted the training and the person’s qualifications to conduct the specific training.   (3)  The names of staff who participated in the training.   (4)  The specific topics addressed during the training.   (5)  A copy of materials distributed to participants.   (6)  A copy of materials that were used during the training.   (7)  Department approval of the training.Discussion: This section of the regulation outlines the required documentation that should be completed by the provider following staff trainings that occur within the provider’s organization.  Agencies may visit the Department’s IBHS website for information on the submission process of provider training for Departmental approval, as well as an explanation of the variety of training that do not require Departmental approval.When the IBHS provider is an ACE provider, trainings do not need departmental approval. However, it is the responsibility of the IBHS provider to ensure trainings cover the content areas specified in the IBHS regulations. Inspection Procedures: OMHSAS Licensing Representatives will review training certificates, department approval letters, training power points or handouts, and any other documentation verifying training to determine compliance with this section of the regulation. Primary Benefit: To ensure documentation consistency for IBHS provider-provided trainings, capturing important information that may be needed for the purpose of verifying details about the training.

Regulation: § 5240.14. Criminal history checks and child abuse certification.Criminal history checks and child abuse certification shall be completed in accordance with 23 Pa.C.S. §§ 6301—6386 (relating to Child Protective Services Law) and 55 Pa. Code Chapter 3490 (relating to protective services). Discussion: Act 12 of 2022, effective January 1, 2022, allows a provider to hire an applicant on a provisional basis for a single period not to exceed 45 days when the following conditions are met: •  The applicant has applied for all required backgrounds/clearances (Pennsylvania State Police, FBI, Child Abuse Clearance) and has supplied the provider with the appropriate completed request forms.•  The employer has no knowledge of information that would disqualify the applicant under Section 6344.(c).•  The applicant swears or affirms in writing that they are not disqualified from employment under Section 6344.(c).•  The employer has received either the Pennsylvania State Police or FBI clearance at the onset of provisional hire. Per updates to Child Protective Services Law (CPSL) published in Act 12 of 2022, effective January 1, 2022, an employee hired on a provisional basis should work in the immediate vicinity of a permanent employee and shall not be permitted alone with children. If the information obtained from a criminal history report reveals the applicant is disqualified from employment, the applicant should be dismissed immediately. If the background clearance that has not been received is not received by the 45th day of employment, the agency should suspend the staff member from employment prior to the 46th date of work. The staff member may be rehired only after all background checks have been received. The criminal history background checks and child abuse certification expire 60 months after the date that appears on the documentation. If the prospective employee or volunteer submits a criminal history background check that was attained at a prior employment or volunteer position, OMHSAS suggests that the employee sign the disclosure statement found on the Keep Kids Safe website. For prospective employees, the “certification purpose” section of the child abuse certification and the “purpose of request” section of the Pennsylvania State Police background check must state “Employment” for it to be acceptable. Additionally, all employees who may have direct contact with children must have a mandated reporter training certification from a department contracted provider or from a provider that appears on the list of additional approved courses found on the Keep Kids Safe website. As outlined in 23 Pa. C.S. § 6383 Education and training. (c)(3), mandated reporter training certification must be completed within 90 days of hire and certifications expire 60 months after the date on that appears on the certification. When criminal history background checks return a positive result, but not a result that disqualifies the applicant from employment in a position that has contact with children, the program should base its decision by reviewing and considering factors such as the nature of the crime; facts surrounding the conviction; time elapsed since the conviction; the evidence of the individual’s rehabilitation; the nature and requirements of the job and the performance of individualized risk assessments. There are four possible criminal history background check results:No Record – The employee has no criminal record.Record Attached – The employee has a criminal record, and it is attached for the facility to review. “Disposition under Review” or “Disposition Unreported” – The employee has a criminal record, but the charges, the type/grade and/or outcome of the charges are not listed.  Information about missing charges or types/grades of offenses can be obtained from the municipality in which the person was charged. “Adjudicated Delinquent” – An adjudication of delinquency is not a criminal conviction.  If the facility is not sure whether the background check shows a criminal conviction or an adjudication of delinquency, it should instruct the employee to obtain additional documentation about the offense.   Further questions can also be directed to the local OMHSAS regional licensing office or the Department’s Criminal Background Record Unit at 717-265-7887. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form and CPSL tracking document, staff clearances, and mandated reporter training certificate/verification at the first visit after hire, and then 10% of existing staff annually.  Primary Benefit: To ensure the health and safety of the individuals served by the provider.

Regulation: § 5240.14. Criminal history checks and child abuse certification.(b)  An IBHS provider shall have written policies and procedures to ensure that staff having contact with children or youth comply with 23 Pa.C.S. §§ 6301—6386 and 55 Pa. Code Chapter 3490, including mandated reporting and training requirements.Discussion: Provider policies and procedures should reflect the training, clearance, and background check requirements of the Child Protective Services Law, and include procedures to assure staff making hiring choices fulfill these requirements. The Department suggests that policies and procedures should also include the process to ensure staff are retrained within the required timeframe. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form and CPSL tracking document, staff clearances, and mandated reporter training certificate/verification at the first visit after hire, and then and 10 % of existing staff annually. Primary Benefit: To ensure the health and safety of the individuals served by the provider.

SERVICE PLANNING AND DELIVERY

Regulation: § 5240.21. Assessment.(a)  Within 15 days of the initiation of services and prior to completing an ITP, a face-to-face assessment shall be completed for the child, youth or young adult by an individual qualified to provide behavior consultation services or mobile therapy services.Discussion: As required by section § 5240.21(c)(7) of the IBHS regulations, the child should be assessed across the home, school and other community settings.OMHSAS interprets the initiation of services to mean the first day an individual service is provided. This includes the first day an assessment is conducted. The timeframes used in the IBHS regulations are for calendar days.An IBHS provider who admits a child, youth, or young adult transferred from another IBHS provider may accept and work off of an assessment completed by the other IBHS provider as long as it is within 12 months of the date the assessment was completed and there is no occurrence that requires an assessment update as outlined in § 5240.21(e), otherwise a new assessment must be completed. When an IBHS provider is accepting an assessment completed by a different provider, the assessment should be reviewed to ensure it contains all the required elements of an assessment. If the assessment is deficient in any of the required elements, the provider may conduct a new assessment or create an addendum to the assessment to include the missing information. The addendum containing the missing elements of the assessment should be included in the individual record along with the transferred assessment and should be signed and dated by the staff member who conducted assessment of the missing elements within 15 days of the initiation of services at the IBHS provider. The assessment should be updated based off of the date that the transferred assessment was completed (the date that the assessment was signed by the staff member of the different IBHS provider). Even if an addendum is added to the assessment it should be updated based off of the original assessment date.A best practice evaluation does not need to be conducted but can be conducted if clinically indicated. A best practice evaluation should meet regulatory requirements for a written order for the services ordered (Individual, ABA or Group services) if used as a written order. An assessment is required regardless of if a best practice evaluation was completed. Unlike a best practice evaluation, the assessment should take place across all environments (home, school, community settings).If a psychological evaluation includes all components required to be included in the assessment, an assessment is still required unless the psychological evaluation was conducted across the home, school and community setting. The level of detail of the assessment may vary based on the information that was included in the psychological evaluation.OMHSAS suggests, to be consistent with clinical best practice, that individuals who complete functional behavior assessments (FBA) should have completed a training provided by the Bureau of Supports for Autism and Special Populations, formerly Bureau of Autism Services, or have completed one of the BCBA credential programs offered by a university.If an individual receives multiple IBHS services (Individual, ABA, Group, EBT) from the same IBHS provider, a separate assessment should be completed for each service. Accordingly, the individual record should document the start date of each service if they are not started on the same date. Inspection Procedures: OMHSAS Licensing Representatives will review individual records including initial assessments to determine compliance with this section of the regulation. When FBAs are conducted, OMHSAS Licensing Representatives will review the staff file to verify they have a Bureau of Supports for Autism and Special Populations’ FBA training certificate, a BCBA, or a master’s degree/graduate certificate in ABA. Primary Benefit: To ensure assessments are completed in a timely fashion as outlined in the regulation.

Regulation: § 5240.21. Assessment.(b)  The assessment shall be completed in collaboration with the child, youth, young adult or parent, legal guardian or caregiver of the child or youth, as appropriate.Discussion: OMHSAS interprets this section to mean that a provider should include documentation that shows collaboration occurred which could include an account in the progress note, a statement within the assessment that shows all parties involved in the assessment. Inspection Procedures: OMHSAS Licensing Representatives will review the initial and ongoing assessment and other progress notes or other documentation that supports the collaboration to determine compliance with this section of the regulation. Primary Benefit: To ensure collaboration has occurred between the assessor and the child/caregiver and has been included in the assessment of strengths and needs.

Regulation: § 5240.21. Assessment.(c)  The assessment shall be individualized and include the following:   (1)  The strengths and needs across developmental and behavioral domains of the child, youth or young adult.   (2)  The strengths and needs of the family system in relation to the child, youth or young adult.   (3)  Existing and needed natural and formal supports.   (4)  The specific services, skills, supports and resources the child, youth or young adult requires to address the child’s, youth’s or young adult’s identified therapeutic needs.   (5)  The specific supports and resources, if any, the parent, legal guardian or caregiver of the child, youth or young adult requires to assist in addressing the child’s, youth’s or young adult’s identified therapeutic needs.   (6)  Clinical information that includes the following:     (i)   Treatment history.     (ii)   Medical history.     (iii)   Developmental history.     (iv)   Family structure and history.     (v)   Educational history.     (vi)   Social history.     (vii)   Trauma history.     (viii)   Other relevant clinical information.   (7)  The child’s, youth’s or young adult’s level of developmental, cognitive, communicative, social and behavioral functioning across the home, school and other community settings.   (8)  The cultural, language or communication needs and preferences of the child, youth or young adult and the parent, legal guardian or caregiver.Discussion: Agencies may use standardized assessment tools (i.e. Vineland, OHIO Scales, CANS, CAFAS), but if these tools do not cover all of the required elements of this section, the additional sections should be assessed and included as an addendum or an attachment to the assessment. Similarly, assessments required by managed care organizations or private insurance providers may be used. However, if required elements are not contained in the assessment, the information should be included as an addendum or an attachment to the assessment. Inspection Procedures: OMHSAS Licensing Representatives will review individual files and any documents that are included in the initial or ongoing assessments.  Primary Benefit: To ensure a comprehensive assessment has been completed as outlined in the regulation.  In addition, to provide consistency in the information shared to enhance quality of services.

Regulation: § 5240.21. Assessment.(d)  The assessment shall include a summary of the treatment recommendations received from health care providers, school or other service providers involved with the child, youth or young adult.Discussion: OMHSAS considers this information a vital piece of an assessment because behaviors may be different across settings. In order to verify that this requirement has been met, OMHSAS interprets this section to require the assessment to list the providers who submitted treatment recommendations.  Inspection Procedures: OMHSAS Licensing Representatives will review individual files and any documents that are included in the initial or ongoing assessments. Primary Benefit: Ensures that assessments are informed by a variety of health care, school and service providers who may provide information that may have been missed if not consulted.

Regulation: § 5240.21. Assessment.(e)  The assessment shall be reviewed and updated at least every 12 months or if one of the following occurs:   (1)  A parent, legal guardian or caregiver of the child or youth requests an update.   (2)  The youth or young adult requests an update.   (3)  The child, youth or young adult experiences a change in living situation that results in a change of the child’s, youth’s or young adult’s primary caregivers.   (4)  The child, youth or young adult has made sufficient progress to require an update.   (5)  The child, youth or young adult has not made significant progress towards the goals identified in the ITP within 90 days from the initiation of the services.   (6)  The child, youth or young adult experiences a crisis event.   (7)  A staff person, primary care physician, other treating clinician, case manager or other professional involved in the child’s, youth’s or young adult’s services provides a reason an update is needed.Discussion: OMHSAS interprets the required timeframe of 12 months to mean 365 days.Managed Care Organizations and private insurance organizations may have additional requirements beyond the minimum standards found in this section. For example, assessment updates may be required when there is a change in a school setting. OMHSAS encourages IBHS providers to work closely with these organizations to be informed of any such requirements. Inspection Procedures: OMHSAS Licensing Representatives will review individual files and any documents that are included in the updated assessments to determine compliance with this section of the regulation. Primary Benefit: Provides consistency in when the assessment is updated and ensures the individual’s assessed needs are driving treatment.

Regulation: § 5240.21. Assessment.(f)  The assessment and all updates shall be signed and dated by the staff person who completed the assessment.Discussion: The initial and updated assessments should be signed by the individual qualified to provide behavior consultation services or mobile therapy services who completed the assessment. OMHSAS does not consider the assessment completed until it has been signed by the staff person who completed the assessment. Therefore, it must be signed within 15 days of the initiation of service for the initial assessment and must be updated within 365 days of the signature date on the previous assessment.If using electronic records, a process for electronic signatures needs to be in place. Electronic signatures and electronic pad signatures are both acceptable, and the use of a PIN is not prohibited. Inspection Procedures: OMHSAS Licensing Representatives will review assessment documents and all updates for the signature and date of the qualified person who completed the assessment. Primary Benefit: To ensure that qualified staff are signing and dating the assessment and all updates.

Regulation: § 5240.21. Assessment.(g)  This section does not apply to ABA services.Discussion: The assessment requirements for individual services are different from the assessment requirements for ABA services. For the assessment requirements for ABA services, see § 5240.85 (relating to assessment). Inspection Procedures: OMHSAS will review and apply the regulations for assessments in Individual services separately from assessments for ABA services. Primary Benefit: To ensure that Individual and ABA services have assessment requirements that fit their service type.

Regulation: § 5240.21. Assessment.(h)  Subsection (a) does not apply to EBT or group services.Discussion: The assessment requirements outlined in subsection (a) for Individual services are different from the assessment requirements for EBT and Group services. For the assessment requirements Group services, see § 5240.95 (relating to assessment). For the assessment requirements for EBT services, see § 5240.102 (relating to assessment and individual treatment plan). Inspection Procedures: OMHSAS will review and apply the regulations for assessments in Individual services separately from assessments for EBT or Group services. Primary Benefit: To ensure that Individual, EBT, and Group services have assessment requirements that fit their service type.

Regulation: § 5240.22. Individual treatment plan.A written ITP shall be completed within 30 days after the initiation of a service and be based on the assessment completed in accordance with §  5240.21 (relating to assessment).Discussion: OMHSAS interprets the completion of an ITP to include the signatures of all required participants, which must be signed off within the 30 day timeframe. The initiation of services is the first day an individual service is provided. This includes the first day an assessment is conducted. The timeframes used in the IBHS regulations are for calendar days.An IBHS provider who admits a child, youth, or young adult transferred from another IBHS provider may accept and provide services utilizing an ITP completed by the other IBHS provider as long as it is within 6 months of the date the ITP was completed. The IBHS provider should review the ITP to ensure it contains all the required elements of an ITP and is signed by all required participants. If the ITP is deficient in any of the required elements, the provider should develop a new ITP. When ITPs developed by a different IBHS provider are used, the ITP should be updated based off of the date the ITP or its most recent update were completed by the previous provider to provide services (the date that all required participants have signed the ITP).  Inspection Procedures: OMHSAS Licensing Representatives will review individual charts for ITPs and the dates they were completed and signed. Primary Benefit: To ensure that there is a treatment plan completed early in services, which guides treatment and is based on the assessment.

Regulation: § 5240.22. Individual treatment plan.(b)  The ITP must include the recommendations from the licensed professional who completed the written order for IBHS in accordance with § 1155.32(a)(1) (relating to payment conditions for individual services).Discussion: 55 Pa Code Chapter § 1155.32(a)(1)(iv) presents the information that must appear in a written order. The following information from the written order must be included in the ITP: the maximum number of hours of each service per month, the settings where services may be provided, and the measurable improvements in the identified therapeutic needs that indicate when services may be reduced, changed or terminated. The “maximum number of hours of each service per month” is in reference to each service type provided: BC, MT, and/or BHT services. The Department suggests that this information should be presented on the ITP and not included as an attachment to the ITP.Although 55 Pa Code Chapter § 1155 is a regulation that outlines requirements for MA payment, providers who do not accept MA should also include the recommendation information as outlined above from the written order in the ITP. Inspection Procedures: OMHSAS Licensing Representatives will review individual charts for ITPs and compare that to the original written order to ensure that the information is captured. Primary Benefit: To ensure that the treatment recommendations from the written order appear on the ITP. This will help to ensure these recommendations are easily monitored and followed during the ITP review and completion process, or if recommendations were adjusted following an assessment, will serve as a historical account of what was initially recommended.

Regulation: § 5240.22. Individual treatment plan.(c)  The ITP shall be strength-based with individualized goals and objectives to address the identified therapeutic needs for the child, youth or young adult to function at home, school or in the community.Discussion: The Department interprets Strength-based treatment plans as plans that focus on the individual’s internal strengths and resourcefulness and not their deficiencies and failures. The ITP should be person-centered and individualized, with goals that address all living environments regardless of the location in which the services are provided. Inspection Procedures: OMHSAS Licensing Representatives will review individual charts and ITPs to determine the ITP is strength-based with individualized goals for the individual to function at home, school or in the community. Primary Benefit: To ensure that treatment is based on the child, youth, or young adult’s strengths and is specifically tailored to their needs.

Regulation: § 5240.22. Individual treatment plan.(d)  The ITP must include the following:   (1)  Service type and the number of hours of each service.   (2)  Whether and how parent, legal guardian or caregiver participation is needed to achieve the identified goals and objectives.   (3)  Safety plan to prevent a crisis, a crisis intervention plan and a transition plan.   (4)  Specific goals, objectives and interventions to address the identified therapeutic needs with definable and measurable outcomes.   (5)  Time frames to complete each goal.   (6)  Settings where services may be provided.   (7)  Number of hours of service at each setting.Discussion: The “number of hours” in subsections (1) and (7) can be written monthly or weekly. The categories for the “setting” outlined in subsection (7) include: home, school, community, and community like settings including center-based.§ 5240.22(d)(3) requires three separate plans, as defined below:Safety Plan – A tool that can be used to prevent a crisis and keep a child, youth or young adult safe.  It includes resources and contact information that can be used when a child, youth or young adult is in a crises.  Crisis Plan – A tool that can be used during a crisis. It provides detailed and individualized information for what to do during a crisis.  Transition Plan – the plan for the child’s, youth’s or young adult’s transition from the crisis event to a return of regular IBHS service provision. Inspection Procedures: OMHSAS Licensing Representatives will review individual charts for ITPs and the presence of each item listed in this section of the regulation. Primary Benefit: To ensure ITPs are detailed and outline a specific service plan for each child, youth, or young adult.

Regulation: § 5240.22. Individual treatment plan.(e)  The ITP shall be developed in collaboration with the child, youth, young adult or parent, legal guardian or caregiver of the child or youth, as appropriate.Discussion: The Department suggests that licensed IBHS providers keep documented evidence of collaboration in the individual records to demonstrate compliance with the regulation. This may include but is not limited to ITP signatures, contact notes, and progress notes connected to the creation and update of the ITP. Inspection Procedures: OMHSAS Licensing Representatives will review the ITP, contact notes, progress notes and other documents in the individual record to determine compliance with this section of the regulation. Primary Benefit: To ensure individuals receiving services, as well as their caregivers, are involved in the development of their treatment goals.

Regulation: § 5240.22. Individual treatment plan.(f)  The ITP shall be reviewed and updated at least every 6 months or if one of the following occurs:   (1)  The child, youth or young adult has made sufficient progress to require that the ITP be updated.   (2)  The child, youth or young adult has not made significant progress towards the goals identified in the ITP within 90 days from the initiation of the services.   (3)  The youth or young adult requests an update.   (4)  A parent, legal guardian or caregiver of the child or youth requests an update.   (5)  The child, youth or young adult experiences a crisis event.   (6)  The ITP is no longer clinically appropriate for the child, youth or young adult.   (7)  A staff person, primary care physician, other treating clinician, case manager or other professional involved in the child’s, youth’s or young adult’s services provides a reason an update is needed.   (8)  The child, youth or young adult experiences a change in living situation that results in a change of the child’s, youth’s or young adult’s primary caregivers.Discussion: OMHSAS suggests that the basis for the ITP update be included and documented in the ITP or in a progress note, as this information will illustrate the nature of the ITP update and provide clarity.Managed Care Organizations and private insurance organizations may have additional requirements beyond the minimum standards found in this section. For example, ITP updates may be required when there is a change in a school setting. OMHSAS encourages IBHS providers to work closely with these organizations to be informed of any such requirements.OMHSAS interprets subsection (6) to require treatment plan updates to occur when a significant increase or decrease in treatment delivery occurs, or when significant changes to the individual’s schedule occur, which would cause the current treatment goals to no longer be clinically appropriate. When a  change to a new IBHS service (e.g. if an individual is receiving individual IBHS services and switches to a Group IBHS service), a treatment plan must be created for the new service. For example, if an individual is receiving Individual IBHS and Group IBHS then there must be a treatment plan for each service. Inspection Procedures: OMHSAS Licensing Representatives will review updated ITPs and accompanying clinical documentation to show the reasons for changes to the ITP to determine compliance with this section of the regulation. Primary Benefit: To ensure ITPs that are guiding treatment are reviewed and updated regularly; or when an update is requested, when a plan-altering life event occurs, or when progress or lack of progress necessitates an ITP update.

Regulation: § 5240.22. Individual treatment plan.(g)  An ITP update must include the elements in subsection (d) and the following:   (1)  A description of progress or lack of progress toward previously identified goals and objectives.   (2)  A description of any new goals, objectives and interventions.   (3)  A description of any changes made to previously identified goals, objectives or interventions.   (4)  A description of new interventions to be used to reach previously identified goals and objectives.Discussion:  In order to objectively identify the progress or lack of progress towards goals and objectives, The Department suggests that the ITP contains measurable goals and objectives. Inspection Procedures: OMHSAS Licensing Representatives will review individual records to include ITP updates to determine compliance with this section of the regulation. Primary Benefit: To ensure consistency in required elements of the ITP update, the ongoing progress measurement, and changes to the plan occur as needed.

Regulation: § 5240.22. Individual treatment plan.(h)  The ITP and all updates shall be reviewed, signed and dated by the youth, young adult or parent or legal guardian of the child or youth, and the staff person who completed the ITP. Discussion: The initial and updated ITPs should be signed by the youth, young adult or parent or legal guardian of the child or youth, and the staff person who completed the ITP. Per § 5240.75(a)-(b), only staff members qualified to provide behavior consultation or mobile therapy services may develop and revise ITPs. OMHSAS suggests that qualifications should be displayed next to the signature as signatures are not always easy to identify. If using electronic records, a process for electronic signatures needs to be in place. Electronic signatures and electronic pad signatures are both acceptable, and the use of a PIN is not prohibited. When ITP or updates are created through telehealth, the staff should sign, but the youth, young adult or parent or legal guardian may give verbal consent via telehealth. OMHSAS considers an ITP to be effective on the date that all required signatures have been documented on the ITP. Accordingly, all signatures outlined in this section and in § 5240.86(i) should be documented in the ITP on or before the due date for the ITP or ITP update completion. For example, an IBHS provider should have the youth, young adult or parent or legal guardian of the child or youth, the staff member who completed the ITP, and the individual who meets the qualifications of a clinical directory (as outlined in § 5240.86(i)) complete the initial ITP and all sign within 30 days from the initial service date. The updated ITP should be signed by those required in this section and in § 5240.86(i) within 6 months (180 days) of the final required signature included in the previous ITP. Inspection Procedures: OMHSAS Licensing Representatives will review initial and updated ITPs for signatures and dates, and/or documentation of participation in the ITP process to determine compliance with this section of the regulation. Primary Benefit: To ensure youth, young adult or parent or legal guardian of the child or youth, and the qualified staff members have documentation to verify their involvement in the creation of the initial and updated ITPs.

Regulation: § 5240.22. Individual treatment plan.(i)  The ITP and all updates shall be reviewed, signed and dated by an individual who meets the qualifications of a clinical director in § 5240.12 (relating to staff qualifications).Discussion: The Department suggests that qualifications should be displayed next to the signature as signatures are not always easy to identify. If the signature is of an individual who meets qualification requirements but is not acting in the role of the clinical director, it is recommended to identify the qualification of this staff member as “clinical director qualified”. OMHSAS interprets this section to require the ITP and updates created by an individual who meets qualifications but is not acting in the role of a clinical director to additionally be signed by another staff member who meets the qualifications of a clinical director. Additionally, OMHSAS suggests that an additional staff who meets the qualification of a clinical director, when possible, signs the ITP and updates when they are created by the staff acting in the role of the clinical director. OMHSAS considers an ITP to be effective on the date that all required signatures have been documented on the ITP. Accordingly, all signatures outlined in this section and in § 5240.86(h) should be documented in the ITP on or before the due date for the ITP or ITP update completion. For example, an IBHS provider should have the youth, young adult or parent or legal guardian of the child or youth, the staff member who completed the ITP (as outlined in § 5240.86(h)), and the individual who meets the qualifications of a clinical directory complete the initial ITP and all sign within 30 days from the initial service date. The updated ITP should be signed by those required in this section and in § 5240.86(h) within 6 months (180 days) of the final required signature included in the previous ITP. Inspection Procedures: OMHSAS Licensing Representatives will review ITPs for signatures of staff qualified to be the clinical director and dates to determine compliance with this section of the regulation. Primary Benefit: To ensure a staff member qualified to be a clinical director is reviewing ITPs and participating in the ITP process.

Regulation: § 5240.22. Individual treatment plan.(j)  This section does not apply to ABA services or group services.Discussion: The ITP requirements for individual services are different from the ITP requirements for ABA and Group services. For the ITP requirements for ABA services, see § 5240.86 (relating to individual treatment plan). For the ITP requirements for Group services, see § 5240.96 (relating to individual treatment plan). Inspection Procedures: OMHSAS will review and apply the regulations for ITPs in Individual services separately from ITPs for ABA and Group services. Primary Benefit: To ensure regulations are appropriate for different service types.

Regulation: § 5240.23. Service provision.IBHS shall be provided in accordance with the child’s, youth’s or young adult’s ITP. Discussion: The ITP provides the framework for how, where, and when medically necessary services will be delivered. Services should only be provided in accordance with the ITP. When medically necessary services determined for the child, youth or young adult are not in accordance with the ITP, the ITP may be reviewed and updated according to § 5240.22(f). In an exceptional case where services are provided not in accordance with the ITP, an explanation of the reasons the services were not provided in accordance with the ITP should be documented in the individual record, per § 5240.41(a)(9).Inspection Procedures: OMHSAS Licensing Representatives will review service documentation to verify the services were indicated in the ITPs prior their provision to determine compliance with this section of the regulation. Primary Benefit: To ensure that services have been assessed and have gone through the ITP process, with all parties and clinical staff, prior to implementation.

Regulation: § 5240.23. Service provision.(b)  Prior to the completion of the ITP, IBHS can be provided if there is a treatment plan for the individual services, ABA services or group services provided.Discussion: A treatment plan is utilized when a child, youth, or young adult needs services while an assessment is being conducted and/or an ITP is being developed. This occurs when a child’s need for service requires initiation prior to the completion of the ITP.The Department suggests that the treatment plan should be written to describe the services and interventions that will be provided. Once the assessment is completed and the ITP is written, the ITP will guide treatment. Inspection Procedures: OMHSAS Licensing Representatives will review service documentation to verify services provided prior to the creation of the ITP were outlined in a treatment plan. Primary Benefit: To ensure that children, youth and young adult may be provided necessary IBHS services while the assessment and ITP are created.

Regulation: § 5240.23. Service provision.(c)  IBHS shall be delivered in home or community-based, clinically appropriate settings as identified in the written order and ITP. Group services may also be delivered in a community like setting.Discussion: In addition to the locations outlined in this section of the regulation, OMHSAS-21-02 Provision of One-to-One Intensive Behavioral Health Services in a Licensed Location states that it may be clinically appropriate to provide medically necessary one-to-one individual services or ABA services at a provider’s licensed location.A provider that is already licensed who wishes to begin providing individual or ABA services at their licensed location should submit an addendum to its service description that includes the information identified in Attachment A of OMHSAS-21-02. Providers that have not already obtained an IBHS license and intend to provide one-to-one individual services or ABA services at a center should include the information identified in Attachment A of OMHSAS-21-02 in their initial service description. Inspection Procedures: OMHSAS Licensing Representatives will review written orders, Assessments, ITPs and other clinical documentation to verify that services are provided in settings outlined in these documents. When individual or ABA services are provided at the licensed location, OMHSAS Licensing Representatives will review the service description to determine information outlined in OMSHAS-21-02 Attachment A is included. Primary Benefit: To ensure the setting of services is clinically indicated and documented throughout the IBHS record.

Regulation: § 5240.23. Service provision.(d)  IBHS shall be provided in accordance with the IBHS provider’s approved service description under § 5240.5 (relating to service description).Discussion: As outlined in § 5240.61(a)(iv), compliance with the provider’s service description should be reviewed annually. If it is determined that an update is needed to the service description, it should be submitted to the provider’s assigned OMHSAS Licensing Representative. Inspection Procedures: OMHSAS Licensing Representatives will review the service description, policies and procedures, individual records and any other documentation which clarifies the provider’s delivery of services. Primary Benefit: To ensure that services provided by the IBHS provider are in a manner outlined in their OMHSAS approved service description.

DISCHARGE

Regulation: § 5240.31. Discharge.(a)  An IBHS provider may discharge a child, youth or young adult when one of the following occurs:   (1)  The child, youth or young adult has completed the goals and objectives in the ITP and no new goals or objectives have been identified.   (2)  The child, youth or young adult is not progressing towards the goals identified in the ITP within 180 days from the initiation of service and other clinical services are in place.   (3)  The child, youth or young adult requires a more restrictive service to meet the child’s, youth’s or young adult’s needs and other clinical services are in place.   (4)  The parent or legal guardian of a child or youth who provided consent to receive services agrees services should be discontinued.   (5)  The youth or young adult agrees services should be discontinued.   (6)  The child, youth or young adult failed to attend scheduled IBHS for 45 consecutive days without any notification from the youth, young adult or the parent, legal guardian or caregiver of the child or youth. Prior to discharge, the IBHS provider made at least three attempts to contact the youth, young adult or the parent, legal guardian or caregiver to discuss past attendance, ways to facilitate attendance in the future and the potential discharge of the child, youth or young adult for lack of attendance.Discussion: The Department interprets the regulation as discharges should only be made in response to one of the occurrences stated in this section of the regulation.  Inspection Procedures: OMHSAS Licensing Representatives will review all discharge documents and accompanying documentation leading up to discharge to determine discharge was carried out due to an acceptable reason outlined in this section of the regulation. Primary Benefit: To ensure services are ended when appropriate or requested.

Regulation: § 5240.31. Discharge.(b)  An IBHS provider shall provide the following information to the youth, young adult or parent, legal guardian or caregiver of the child upon discharge:   (1)  If the child, youth or young adult has been referred to other services, contact information for each service.   (2)  Contact information for the local crisis intervention service.Discussion: OMHSAS believes it is vital for the continuity of services and the safety of the child, youth or young adult to have access to the contact information for referred services and the local crisis intervention service. It is recommended that the contact information should be a part of the discharge summary, but if this is sent separately a copy should be filed as an attachment to the discharge summary in the individual record as verification that this information was sent. Inspection Procedures: OMHSAS Licensing Representatives will review the discharge summary and other accompanying documents for this information. Primary Benefit: To ensure the child, youth, or young adult and the parents or guardians have clear information for post-discharge services and where to get immediate help if a crisis occurs.

Regulation: § 5240.32. Discharge summary.(a)  An individual qualified to provide behavior consultation services, mobile therapy services, behavior analytic services or behavior consultation—ABA services shall complete a discharge summary for the child, youth or young adult that includes the following:   (1)  Summary of the service outcomes.   (2)  Reason for discharge.   (3)  Referral for services other than IBHS if needed.Discussion: The discharge summary should be signed by the staff member as verification that the summary was completed by a staff member who meets the required qualifications.  Inspection Procedures: OMHSAS Licensing Representatives will review the discharge summary and other accompanying documents for this information. Primary Benefit: To ensure there is a detailed summary of services that were provided and there is a plan for services to occur after IBHS discharge, as needed.

Regulation: § 5240.32. Discharge summary.(b)  An IBHS provider shall ensure that the discharge summary is:   (1)  Completed within 45 days after the date of discharge.   (2)  Provided to the youth, young adult or parent, legal guardian or caregiver of the child.Discussion: The discharge summary should be completed within 45 calendar days after the date of discharge. The date of discharge should be considered the date the discharge was decision determined by a reason outlined in § 5240.31(a) (relating to discharge) The date that the discharge was determined should be documented in the individual record.Documentation that verifies the discharge summary was provided to the child, youth, young adult or parent or legal guardian should be kept in the individual record. This could include a contact note, an envelope scan or other means to support that summary was provided. When provider is unable to locate child, youth, young adult, or parent or guardian, documentation should be kept in the individual record that explains the steps that were taken and failed to provide the discharge summary. Inspection Procedures: OMHSAS Licensing Representatives will review the discharge summary and discharge-related records to assure summary was provided within the required time frame and evidence that verifies discharge summary was provided to determine compliance with this section of the regulation.  Primary Benefit: To ensure discharge summaries are completed timely and provided to the youth, young adult, or parent or guardian.

RECORDS

Regulation: § 5240.41. Individual records.(a)  An IBHS provider shall maintain a record for each child, youth or young adult it serves that includes the following:   (1)  Identifying information.   (2)  A written order for IBHS in accordance with §§ 1155.32(a)(1), 1155.33(a)(1) or 1155.34(a)(1) (relating to payment conditions for individual services; payment conditions for ABA services; and payment conditions for group services).   (3)  An assessment and any updates to the assessment in accordance with §§ 5240.21, 5240.85, 5240.95 or 5240.102.   (4)  Presenting problems.   (5)  The ITP and any updates to the ITP in accordance with §§ 5240.22, 5240.86, 5240.96 or 5240.102.   (6)  A treatment plan if services are being provided prior to the completion of the ITP.   (7)  Documentation of any efforts to coordinate care with other services and community supports if needed.   (8)  Documentation of each service provided that includes the following:     (i)   Date and time services were provided, duration of services and setting            where services were provided.     (ii)   Identification of the service provided to address a goal in the ITP.     (iii)   Description of the outcome of the services provided.     (iv)   Signature of the staff person providing the service.   (9)  If services are not provided in accordance with the ITP and written order, an explanation of the reason why services were not provided in accordance with the ITP and written order.   (10)  Consent to treatment and consent to release information forms.   (11)  Discharge summary in accordance with § 5240.32 (relating to discharge            summary).   (12)  Documentation of any use of a manual restraint and a description of how              the use was in accordance with § 5240.6 (relating to restrictive            procedures), including the following:     (i)     The specific behavior addressed.     (ii)    The less intrusive methods of intervention used to address the behavior              prior to initiating the manual restraint used.     (iii)   The specific manual restraint used.     (iv)   The name and training of the staff person who used the manual restraint.     (v)    The duration of the manual restraint.     (vi)   The name of the trained individual who observed the child, youth or               young adult during the application of the manual restraint.     (vii)   The child’s, youth’s or young adult’s condition following the manual               restraint.     (viii)  The date and time the manual restraint was used.     (ix)    The date and time the treatment team was notified of the use of a               manual restraint and the members of the treatment team who were               notified.Discussion: IBHS agencies may keep records electronically or on paper, or a combination of both. There is no requirement that each item identified in this section is documented separately, for example, the presenting problems may be found on an assessment.IBHS must be prescribed through a written order based on a face-to-face interaction with the child, youth or young adult. The order may be written by a licensed physician, licensed psychologist, certified registered nurse practitioner or other licensed professional whose scope of practice includes the diagnosis and treatment of behavioral health disorders and the prescribing of behavioral health services, including IBHS. Licensed individuals should follow the regulations that govern their license and should only sign off on tasks performed by an unlicensed individual if permitted by their licensing regulations. For a written order to continue, it must be written by an individual qualified to write the initial written order. Although 55 Pa Code Chapter § 1155 is a regulation that outlines requirements for MA payment, providers who do not accept MA should also include the written order in the individual record.§ 1155.32(a)(6) states that when a service is continued a new written order is needed within 12 months of the initiation of service. Because the initial written order is valid for 12 months from the date the written order is completed, the timeframe between the first written order and the second written order could be greater than 12 months. To ensure no issues with payment, OMHSAS suggests that IBHS agencies track written order updates from the date of the initiation of service and assure the written order is updated within 12 months of that date.  Per § 1155.32(a)(6): For continued individual services, a child, youth or young adult shall have an order written within 12 months of the initiation of the continued services.However, IBHS agencies that are not seeking MA payment for IBHS are not required to obtain written orders for continued services. These agencies may be required to obtain written orders for continued services by the commercial insurance plans.If an addendum is needed to a written order it is the responsibility of the individual who wrote the written order to determine the process for obtaining a change in the recommendation.The written order should contain the maximum number of hours per month needed for each service. The assessment and ITP will provide more specifics on the delivery of the prescribed hours.OMHSAS suggests that consents to release protected health information contain at a minimum the information required in § 5100.34(f) (relating to consensual release to third parties). Inspection Procedures: OMHSAS Licensing Representatives will fully review individual records for all required items. Primary Benefit: To ensure records include information of importance in the provision of service, and records across IBHS providers include consistent documentation.

Regulation: § 5240.41. Individual records. (b)  The record must be:   (1)  Legible.   (2)  Signed and dated by the staff person writing in the record.   (3)  Reviewed for quality by the administrative director, clinical director or designated quality improvement staff within 6 months of the initial entry. After initial review, subsequent reviews may be limited to new additions to the record and must occur at least annually.Discussion: For quality reviews, the Department suggests that IBHS agencies should keep documentation either in the individual record or in provider records that verify the staff who conducted the review and the date when the review occurred. This review should occur as outlined for the records of all individuals who are receiving IBHS services. The review must occur within 6 months of the date when the first document was included in the individual’s record. Therefore, the individual record should include a record of the date the first document was included. If discharge occurs prior to the required 6 month or annual review, a post-discharge review should occur within the required timeframe. IBHS agencies may incorporate this review into their quality improvement process.If the clinical director conducts the 6 month or annual record review, it may be counted towards the quarterly chart review requirement outlined as a job responsibility of the clinical director in § 5240.11(d)(4). Inspection Procedures: OMHSAS Licensing Representatives will fully review individual records and the documents that verify the quality improvement review occurred to determine compliance with this section of the regulation. Primary Benefit: To ensure provider management is reviewing records for quality and that records are legible.

Regulation: § 5240.41. Individual records.(c)  The record shall be maintained for a minimum of 4 years after the last date ofservice.Discussion: Individual records may be maintained on paper or in an electronic format, or a combination of the two. These records must be maintained a minimum of 4 years after the last date of service. The Department suggests that these records should be maintained in a manner that allows for easy access. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures that outline record retention and may request these records as needed to determine compliance with the section of the regulation. Primary Benefit: To ensure records are complete and stored in the event they are needed.

Regulation: § 5240.42. Provider records.(a)  An IBHS provider shall maintain records that contain the following for at least 4 years:   (1)  Inspection reports, certifications or licenses issued by State and local agencies.   (2)  A detailed provider service description in accordance with § 5240.5 (relating to service description).   (3)  A written emergency plan that includes, at a minimum, a plan for natural disasters, inclement weather and medical emergencies.   (4)  Human resources policies and procedures that address the following:     (i)     Job descriptions for staff positions.     (ii)    Staff work schedules and time sheets.     (iii)   Criminal history checks, child abuse certifications and training on and              compliance with the mandated reporting requirements in 23 Pa.C.S. §§ 6301—6386 (relating to Child Protective Services Law) and 55 Pa. Code Chapter 3490 (relating to protective services).   (5)  Written agreements to coordinate services in accordance with § 5240.7 (relating to coordination of services).   (6)  Daily schedules for group services if providing group services.   (7)  Quality improvement plan in accordance with § 5240.61 (relating to quality improvement requirements).Discussion: Provider records may be maintained on paper or in an electronic format, or a combination of the two. The documents outlined in § 5240.42(a)(1)&(6) must be maintained a minimum of 4 years after the documents’ creation. OMHSAS interprets the requirements of § 5240.42(a)(2)(3)(4)(5)(7) to require the IBHS provider to maintain these specific records for at least 4 years after the date in which these documents are updated and replaced with new versions, or obsoleted. The IBHS provider should continue to maintain the records outlined in § 5240.42(a)(2)(3)(4)(5)(7) beyond 4 years if they are unchanged since they are important to the continuity of the provision of services. All provider records outlined in this section of the regulation should be maintained in a manner that allows for easy access.Inspection Procedures:  OMHSAS Licensing Representatives will review policies and procedures that outline record retention and may request these records as needed to determine compliance with the section of the regulation. Primary Benefit: To ensure records are complete and stored in the event they are needed.

Regulation: § 5240.42. Provider records. (b)  An IBHS provider shall maintain staff personnel records that include the following for at least 4 years after the staff person is no longer employed by the provider:   (1)  Documentation of staff credentials or qualifications.   (2)  Documentation of completion of required training for staff, including completion of continuing education credits required for professionally licensed staff in accordance with the applicable professional regulations.   (3)  Criminal history checks and child abuse certifications.   (4)  The staff person’s individual training plan in accordance with § 5240.13 (relating to staff training plan). Discussion:  A provider should obtain an official record of a prospective employee’s credentials/licensure.  If the provider human resources staff makes a copy of the original transcript or diploma for the staff record, the human resources staff should sign and date the copy to indicate an original transcript or diploma was viewed. If a provider utilizes a university or college website to verify qualifications, human resources staff should initial a printout of the transcript and indicate that the human resources staff accessed the record through a university or college website.It is recommended that the provider keeps a record of training in each staff member’s personnel files instead of a file devoted to training for the entire IBHS provider because training files must be retained for at least 4 years after staff member is no longer employed with the provider per § 5240.42(b)(2). An alternative recommendation would be to keep training records provider-wide and in the event a staff member is no longer employed, transfer the training documents into the employee record to be saved for four years after staff is no longer employed at the provider. Inspection Procedures: OMHSAS Licensing Representatives will review the human resources files for staff who no longer are employed at the provider to ensure these records are maintained as required in this section of the regulation.  Primary Benefit: To ensure records are complete and stored in the event they are needed.

Regulation: § 5240.43. Record retention and disposal.An IBHS provider shall ensure that records that contain protected health information, both written and electronic, are secured, maintained and disposed of in accordance with applicable Federal and State privacy and confidentiality statutes and regulations.Discussion: The Department suggests that each provider should have a policy and procedure that outlines how records will be stored, protected, secure and disposed of. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, individual records, staffing records, provider records, and may interview staff to determine compliance with this section of the regulation. Primary Benefit: To ensure records are maintained according to applicable Federal and State regulations

NONDISCRIMINATION

Regulation: § 5240.51. Nondiscrimination.An IBHS provider may not discriminate against staff or children, youth or young adults receiving services on the basis of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity or expression, sexual orientation, national origin or age, and shall comply with applicable Federal and State statutes and regulations.Discussion: The Department interprets the regulation to mean that each IBHS provider has an annual requirement to verify that employment and provision of services are conducted in a nondiscriminatory manner, through the submission of the Bureau of Equal Opportunity’s (BEO) civil rights questionnaire.  Information on the process to submit the annual BEO civil rights questionnaire can be found in this regulatory compliance guide at PART 4: Additional Resources – Bureau of Equal Opportunity Civil Rights Compliance Contact Information. OMHSAS suggests that the child, youth, or young adult and the parent or guardian are provided a nondiscrimination notice during admission. Inspection Procedures: OMHSAS Licensing Representatives will review the annual BEO approval letter and provider policies on non-discrimination. Primary Benefit: To ensure IBHS agencies have nondiscriminatory practices in employment and provision of services.

QUALITY IMPROVEMENT

Regulation: § 5240.61. Quality improvement requirements.(a)  An IBHS provider shall establish and implement a written quality improvement plan that meets the following requirements:   (1)  Provides for an annual review of the quality, timeliness and appropriateness of services that includes the following:     (i)     Review of individual records.     (ii)    Review of individual and family satisfaction information.     (iii)   Assessment of the outcomes of services delivered and if ITP goals have              been completed.     (iv)   Evaluation of compliance with the provider’s approved service description              and licensure requirements in this chapter.   (2)  Identifies the methodology for the review of provider and individual records          that includes the following:     (i)     Method for establishing sample size of provider and individual records.     (ii)    Frequency of review of the provider and individual records to prepare for              the annual quality review in subsection (a)(1).     (iii)   Staff’s qualifications who perform the review.Discussion: The Department interprets this regulation as requiring the following from IBHS agencies: to keep on record a plan that outlines the provider’s Quality Improvement (QI) activities and to enact the plan for an annual review. The Department suggests that IBHS agencies should use a standardized template for the review of individual records to ensure the reviews create quality data. The QI plan should identify the source and/or methods used to attain the individual and family satisfaction information. The QI plan should contain the staff qualifications and title for those who conduct a review of the provider and individual records. IBHS provider should ensure the currently approved provider service description and the licensure requirements of this regulation are used when evaluating compliance. Inspection Procedures: OMHSAS Licensing Representatives will review the provider’s QI plan, documentation utilized to conduct the annual review, policy and procedures and other related documentation to determine compliance with this section of the regulation. Primary Benefit: To ensure standard QI measures are in place with identified methodologies, and a review is conducted annually.

Regulation: § 5240.61. Quality improvement requirements.(b)  An IBHS provider shall prepare an annual quality report that includes the following:   (1)  Analysis of the findings of the annual quality review required under          subsection (a)(1).   (2)  Identification of the actions to address annual review findings.Discussion: The Department suggests that IBHS agencies utilize their QI plan, as outlined in § 5240.61(a), to develop a quality report. This formalized report should be produced annually at a minimum and shall include the findings and actions to address the findings. Inspection Procedures: OMHSAS Licensing Representatives will review the annual QI report, the identified actions to address the findings, and any documentation that verifies the steps taken to address the findings. Primary Benefit: To ensure the QI process is formalized, analyzed, and used to inform needed provider changes.

Regulation: § 5240.61. Quality improvement requirements.(c)  An IBHS provider shall make annual quality reports available to the public upon request.Discussion: In order for an IBHS provider to fulfill the requirement of this section, the process to request an annual report must be made available to the public. Recommendations to make the report public may include, but are not limited to: posting on the provider/provider website, in the provider/provider telephone interactive voice response, and on a notification hung in the lobby/offices. Providing the youth, young adult or parent, legal guardian or caregiver of a child, youth, or young adult the notification required at admission per 5240.61.(d) does not fulfill this requirement because the Department interprets the term “public” to include individuals beyond those who are currently served by the IBHS provider.Because some providers may create internal QI reports that detail information beyond what is required in this section, it is allowable to have a separate QI report that is formatted for public consumption. When an IBHS provider creates both an internal and public QI report, the public QI report should minimally contain the required elements outlined in § 5240.61(b). Inspection Procedures: OMHSAS Licensing Representatives will verify documentation of how each provider makes its report available to the public each year. Primary Benefit: To allow interested stakeholders the opportunity to review annual quality reports and be informed of the provider’s quality improvement initiatives.

Regulation: § 5240.61. Quality improvement requirements.(d)  An IBHS provider shall provide written notification that a copy of the annual quality report may be requested by a youth, young adult or parent, legal guardian or caregiver of a child, youth or young adult upon admission to services.Discussion: The notification shall be provided to the child, youth, young adult or parent, legal guardian as part of the intake process, upon admission, with the notification documented in the individual’s record. Inspection Procedures: OMHSAS Licensing Representatives will review the process for notifying clients about the annual quality report, and admission documents/handbooks to determine compliance with this section of the regulation. Primary Benefit: To ensure that individuals are aware of the QI report available to them from the provider.

INDIVIDUAL SERVICES

Regulation: § 5240.71. Staff qualifications for individual services.(a)  Except as set forth in subsection (b), individuals who provide individual services through behavior consultation services must meet one of the following:   (1)  Be licensed in this Commonwealth as a behavior specialist.   (2)  Have a certification as a BCBA or other graduate-level certification in behavior analysis that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.   (3)  Have a graduate degree in ABA from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or have an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.   (4)  Have a minimum of 1 year of full-time experience in providing mental health direct services to children, youth or young adults and a graduate degree in psychology, social work, education, or counseling from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.   (5)  Completed a clinical or mental health direct service practicum and have a graduate degree in psychology, social work, education, counseling or a related field from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or have an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.Discussion: The Department interprets the regulation to mean that the “clinical or mental health direct service practicum” outlined in § 5240.71(a)(5) may include field experience in the provision of mental health services obtained as part of one of the listed degrees. Clinical or mental health direct care experience not obtained as part of a graduate degree is not acceptable. A provider may count part-time experience as part of the experience required to provide BC services. To meet qualification requirements under § 5240.71(a)(4), part-time experience providing BC services should be equivalent to 1 year of full-time experience.  Inspection Procedures: OMHSAS Licensing Representatives will review credentials for all new BC staff during initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure BC services are provided by qualified staff as outlined in the regulation.

Regulation: § 5240.71. Staff qualifications for individual services.(b)  Individuals who provide behavior consultation services to children diagnosed with ASD for the treatment of ASD shall be licensed in this Commonwealth as a psychologist, professional counselor, marriage and family therapist, clinical social worker, social worker, behavior specialist, certified registered nurse practitioner or a professional with a scope of practice that includes overseeing the provision of ABA services.Discussion: IBHS agencies should ensure that only staff members who provide BC services to children with ASD for the treatment of ASD have appropriate staff qualifications. The provider shall have a process and/or plan to ensure children who receive BC services for the treatment of ASD are assigned only staff who are qualified by this section, including the process to ensure staff filling in on an as-needed basis meet these qualification requirements.Act 62 of 2008 requires an “autism service provider”, including behavior specialist, to be licensed in the Commonwealth.  Inspection Procedures: OMHSAS Licensing Representatives will review credentials for all new BC staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. OMHSAS Licensing Representatives will review progress notes, assessments, treatment plans, and cross-reference the BC staff who provided services to a child with ASD to determine that they meet qualification requirements. Primary Benefit: To ensure BC services are provided to children with ASD only by qualified staff as outlined in the regulation.

Regulation: § 5240.71. Staff qualifications for individual services.(c)  Individuals who provide individual services through mobile therapy services shall meet one of the following:   (1)  Be licensed in this Commonwealth as a psychologist, professional counselor, marriage and family therapist or clinical social worker.   (2)  Be licensed in this Commonwealth as a social worker or a behavior specialist and have a graduate degree that required a clinical or mental health direct service practicum from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or have an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.   (3)  Have a minimum of 1 year of full-time experience in providing mental health direct services to children, youth or young adults and a graduate degree with at least nine credits specific to clinical practice in psychology, social work or counseling from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.   (4)  Completed a clinical or mental health direct service practicum and have a graduate degree with a least nine credits specific to clinical practice in psychology, social work, education, counseling or a related field from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or have an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.Discussion: OMHSAS interprets the “nine credits specific to clinical practice” requirement outlined in § 5240.71(c)(3) to involve only credits that were obtained for clinical practice and not clinical theory. OMHSAS suggests that providers consult the applicant’s transcripts, and the course descriptions when the transcript is unclear. The “mental health direct service practicum” outlined in § 5240.71(c)(4) may include field experience in the provision of mental health services obtained as part of one of the listed degrees. Clinical or mental health direct care experience not obtained as part of a graduate degree is not acceptable under this category. A provider may count part-time experience as part of the experience required to provide MT services. To meet qualification requirements under § 5240.71(c)(3), part-time experience providing mental health direct services to children should be equivalent to 1 year of full-time experience.  An individual who provides mobile therapy services should have completed coursework that prepares the individual to provide mobile therapy services. This coursework should include different therapy approaches as well as instruction in mental health diagnoses. Individuals providing mobile therapy services should complete coursework that includes training in the diagnostic criteria of mental and behavioral health disorders, as well as training in conducting mental health assessments. Some examples of acceptable coursework include counseling, psychotherapy, family therapy, mental health counseling approaches and interventions, child and adolescent counseling, psychopathology, diagnosis and treatment of behavior disorders, group counseling and psychotherapy, theories of counseling with children and adolescents and structural family therapy. Inspection Procedures: OMHSAS Licensing Representatives will review credentials for all new staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure MT services are provided by qualified staff as outlined in the regulation.

Regulation: § 5240.71. Staff qualifications for individual services.(d)  By January 1, 2021, individuals who provide individual services through BHT services shall meet one of the following:   (1)  Have a certification as a BCaBA.   (2)  Have a certification as an RBT.   (3)  Have a certification as a BCAT.   (4)  Have a behavior health certification or behavior analysis certification from an organization that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.   (5)  Have a high school diploma or the equivalent of a high school diploma and have completed a 40-hour training covering the RBT Task List as evidenced by a certification that includes the name of the responsible trainer, who is certified as a BCBA or BCaBA.   (6)  Have a minimum of 2 years of experience in the provision of behavioral health services.Discussion: The Department interprets this section of the regulation to mean that IBHS agencies may hire individuals who are not yet qualified to provide BHT services because they lack certifications required under § 5240.71.(d)(1)-(4) or the 40 -hour training required under § 5240.71(d)(5) in order to allow training or certification to be obtained while employed at the provider, however, IBHS services may not be provided by these individuals until they meet one of the qualifications of this section of the regulation. Such IBHS agencies should have a process to verify that no staff provides services prior to when the qualifications are met.The “40-hour training covering the RBT Task List” required under § 5240.71(d)(5) is issued by the individual BCBA or BCaBA certified trainer responsible for the training that confirms that the 40-hour RBT training was completed.The “2 years of experience in the provision of behavioral health services” required under § 5240.71(d)(6) includes any position that implemented a behavioral health treatment plan. While general experience working in a pre-school or daycare would not be considered behavioral health experience, implementing a behavioral health treatment plan while a child was in a pre-school or daycare setting would be considered behavioral health experience.  For staff members who are qualified under § 5240.71(d)(5), when the staff member has attained 2 years of experience in the provision of behavioral health services, they may be deemed qualified under § 5240.71(d)(6). This may be important to track for IBHS agencies because there are less stringent supervision requirements for staff members who are qualified under § 5240.71(d)(6). Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, job descriptions, credentials, educational transcripts/degrees and trainings, and may search the USDE or CHEA website to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review credentials for all new staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure BHT services are provided by qualified staff as outlined in the regulation.

Regulation: § 5240.72. Supervision of staff who provide individual services.(a)  An individual who meets the qualifications of a clinical director shall provide the following supervision to individuals who provide behavior consultation services and mobile therapy services:   (1)  One hour of individual face-to-face supervision per month that includes oversight of the following:     (i)    The interventions being implemented.     (ii)    The child’s, youth’s or young adult’s progress towards the goals of the              ITP.     (iii)   Consideration of adjustments needed to the ITP.     (iv)   The staff person’s skill in implementing the interventions in the ITP   (2)  If the individual who provides behavior consultation services or mobile therapy services supervises an individual who provides BHT services, the individual shall receive an additional hour of face-to-face supervision per month that includes a discussion of the BHT services being provided.   (3)  Thirty minutes of direct observation of services being provided every 6 months.Discussion:  The Department interprets this section of the regulation to mean that any individual who meets the qualifications of a clinical director can provide supervision to individuals who provide BC and MT services. It is up to the provider to decide how to utilize individuals who meet the qualifications of a clinical director to meet the supervision requirements. However, the clinical director is ultimately responsible for ensuring that staff who provide IBHS are supervised in accordance with the IBHS regulations. If a clinical director provides BC or MT services, they should make arrangements to have peer supervision by an individual who meets the qualifications of a clinical director. If a clinical director does not typically provide BC or MT services but will provide these services when an individual who normally provides these services is unavailable, the IBHS provider should develop a policy and procedure to outline the circumstances when the clinical director will provide services and how the clinical director will seek peer supervision to cover the period when the clinical director is providing services. At a minimum, this should include the name of the individual who will conduct the peer supervision, confirmation that the individual who provides peers supervision meets the qualification of a clinical director, and the method, frequency, and duration of the supervision. The policy and procedure will be reviewed by OMHSAS as part of licensing. The additional hour of supervision required under § 5240.82(a)(2) is not necessary for a clinical director who is supervising staff, nor is there a requirement that the peer providing supervision of the clinical director sign off on any documents in the individual records. The hour(s) of supervision required may be met by a combination of shorter-length supervision sessions that add up to the required timeframe. The additional hour of supervision required under § 5240.72(a)(2) when an individual supervises a BC or MT who provides BHT services may be provided through group supervision as long as the BC or MT receives one hour of individual face-to-face supervision.When a staff member provides multiple types of IBHS services, they should receive supervision related to each IBHS service they deliver. However, there is no need to supervise the service provision separately because supervision related to multiple types of IBHS can occur concurrently. For example, staff who provide both MT and BC-ABA can receive a total of 1 hour of supervision per month which covers both services rather than receiving separate 1 hour per month supervision addressing MT services and another 1 hour per month supervision addressing BC-ABA services. If there are different supervision requirements, staff providing multiple types of IBHS should receive the highest amount of supervision required for the IBHS the staff person provides. Supervision of staff providing multiple types of IBHS should be conducted by a qualified supervisor.  A supervisor is qualified if they are permitted to conduct the supervision of each of the services provided by the staff member under the IBHS regulation. The IBHS regulations require direct observation to occur while staff are providing services directly to the child, youth or young adult. As a result, observing a staff person who provides MT, BC, BA, BC-ABA conduct a treatment team meeting would not count as direct observation. Observing staff conduct a treatment team meeting could be considered supervision. As outlined in § 5240.72(f), documentation of supervision must be included in the supervised staff member’s personnel file. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures for clinical director supervision when clinical director provides IBHS services, to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review supervision documentation for all new staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure regular supervision and direct observation for all BC and MT staff to maintain quality of care.

Regulation: § 5240.72. Supervision of staff who provide individual services.(b)  An individual who meets the qualifications of a clinical director or is qualified to provide behavior consultation services or mobile therapy services shall provide the following supervision to individuals who provide BHT services:   (1)  One hour of supervision each week if the individual who provides BHT services works at least 37.5 hours per week or 1 hour of supervision two times a month if the individual who provides BHT services works less than 37.5 hours a week. An individual who provides BHT services must receive 1 hour of individual face-to-face supervision each month.   (2)  If the individual has not previously provided BHT services, 6 hours of onsite supervision during the provision of services to a child, youth or young adult prior to providing services independently.   (3)  One hour of direct observation of the provision of individual services to a child, youth or young adult during the implementation of the ITP every 4 months, unless the individual meets the qualifications to provide BHT services included in §  5240.71(d)(5) (relating to staff qualifications for individual services). If the individual meets the qualifications to provide BHT services included in §  5240.71(d)(5), the individual shall receive 1 hour of direct observation of the provision of individual services to a child, youth or young adult during the implementation of the ITP every 2 months.   (4)  The supervision must include oversight of the following:     (i)     The interventions being implemented.     (ii)    The child’s, youth’s or young adult’s progress towards the goals of the              ITP.     (iii)   Consideration of adjustments needed to the ITP.     (iv)   The staff person’s skills in implementing the interventions in the ITP.Discussion:  The Department interprets this section of the regulation to mean that any individual who meets the qualifications of a clinical director, or is qualified to provide BC or MT services, can provide supervision. It is up to the provider to decide how to utilize individuals who meet these qualifications to meet the supervision requirements. However, the clinical director is ultimately responsible for ensuring that staff who provide IBHS are supervised in accordance with the IBHS regulations.The 37.5 hours per week requirement used to determine the frequency of supervision includes all time the individual works, including hours the individual is not providing face-to-face BHT/BHT-ABA services.The hour(s) of supervision required may be met by a combination of shorter-length supervision sessions that add up to the required timeframe. In order to verify requirements of § 5240.72(b)(2) for newly hired BHT staff members who have not previously provided BHT services, the IBHS provider must document the date when the BHT staff begins providing services independently. Direct observation is not counted towards the required hours of supervision. Rather, it is required in addition to the required hours of supervision. When a staff member provides multiple types of IBHS services, they should receive supervision related to each IBHS service they deliver. However, there is no need to supervise the service provision separately because supervision related to multiple types of IBHS can occur concurrently. For example, staff who provide both BHT and BHT-ABA can receive a total of 1 hour of supervision per month which covers both services rather than receiving separate 1 hour per month supervision addressing BHT services and another 1 hour per month supervision addressing BHT-ABA services. If there are different supervision requirements, staff providing multiple types of IBHS should receive the highest amount of supervision required for the IBHS the staff person provides. Supervision of staff providing multiple types of IBHS should be conducted by a qualified supervisor.  A supervisor is qualified if they are permitted to conduct the supervision of each of the services provided by the staff member under the IBHS regulation. The Department expects that there will be a need for supervision to occur outside of the presence of the child, youth or young adult. For example, a supervisor may need to discuss feedback with an individual providing BHT services or BHT-ABA services which may not be appropriate to discuss in front of the child, youth, young adult or caregiver.As outlined in § 5240.72(f), documentation of supervision must be included in the supervised staff member’s personnel file. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, and supervision tracking documents to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review supervision documentation for all new staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure regular supervision and direct observation for all BHT staff to maintain quality of care.

Regulation: § 5240.72. Supervision of staff who provide individual services.(c)  An individual may supervise a maximum of 12 full-time equivalent staff who provide individual services, but only nine of the full-time equivalent staff can provide BHT services. Discussion: The Department interprets this section of the regulation to mean that full-time equivalency (FTE) includes time spent in both direct service provision and non-billable activities related to behavioral health services. When determining if an individual who provides IBHS services works a full-time equivalent, the IBHS provider should include all hours the individual is considered to be working for the IBHS provider, not the specific level of service. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, and personnel files to determine compliance with this section of the regulation. Primary Benefit: To ensure supervision is provided in a manner that allows individualized supervision.

Regulation: § 5240.72. Supervision of staff who provide individual services.(d)  Group supervision may be provided to no more than 12 staff who provide individual services, but only nine of the staff can provide BHT services. Discussion: A qualified supervisor is permitted to supervise a total of 12 staff in a group supervision setting, of which up to 9 may be staff who provide BHT services. For example, a supervisor may provide group supervision to 9 BHTs and 3 BCs, but a group containing 10 BHTs and 2 BCs would not be allowable under the regulation.  The Department interprets this section of the regulation to mean that IBHS agencies may include staff who provide multiple service types (Individual, ABA, Group, EBT) in group supervision as long as all staff in the group have at least one service type in common. For example, it would be appropriate to include a staff member who provides both ABA and Individual services into group supervision of staff who provide Individual services. It would not, however, be appropriate to include a staff member who provides only individual services into group supervision with staff who provide only ABA. A qualified supervisor cannot supervise multiple groups of 12 staff at different times. As outlined in § 5240.72(f), documentation of supervision must be included in the supervised staff member’s personnel file. Therefore, if one group supervision note is created it should be copied and included in all supervised staff members personnel files. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, and personnel files to determine compliance with this section of the regulation. Primary Benefit: To ensure supervision provided in a group setting is provided in a ratio that allows individualized attention for each staff member.

Regulation: § 5240.72. Supervision of staff who provide individual services.(e)  Face-to face supervision may be delivered through secure, real-time, two-way audio and video transmission that meets technology and privacy standards required by the Health Insurance Portability and Accountability Act of 1996 (Pub.L. No. 104-191).Discussion: The Department interprets this section of the regulation to mean that face-to-face supervision may include the use of HIPAA-compliant audio-video communication products. Face-to-face supervision may not include supervision conducted using audio-only telephone conversation to count towards formal supervision requirements. Audio-only telephone supervision may be conducted in addition to the required formal supervision.Direct observation may be considered Face-to-face supervision and therefore direct observation may be delivered through secure, real-time, two-way audio and video transmission.  Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, supervision tracking documents to determine method used for supervision, documentation that verifies any utilized audio-video platform is HIPAA compliant, and the provider’s HIPAA business associate agreement(s) with utilized audio-video platform providers to determine compliance with this section of the regulation. Primary Benefit: To ensure adequate clinical support is provided to staff providing ABA services in a format that protects privacy and security of protected health information.

Regulation: § 5240.72. Supervision of staff who provide individual services.(f)  A supervisor shall maintain documentation about each supervision session in the supervised staff person’s personnel file that includes the following:   (1)  The date of the supervision session.   (2)  The location and modality of the session, such as in-person or through secure, real-time, two-way audio and video transmission.   (3)  The format of the session, such as individual, group or onsite.   (4)  The start and end time of the supervision session.   (5)  A narrative summary of the points discussed during the session.   (6)  The signature and signature date of the supervisor and the staff person receiving supervision.Discussion: The Department suggests that a record of each supervision session (individual supervision and, if applicable, group supervision) should be kept and be considered part of personnel records. IBHS agencies may additionally keep a provider-wide record of each supervision session and supervision tracking documentation outside of personnel records. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, and supervision tracking documents to determine compliance with this section of the regulation.  Primary Benefit: To ensure that supervision is documented in a standard way with detailed information.

Regulation: § 5240.72. Supervision of staff who provide individual services.(g)     A supervisor shall be available to consult with staff during the hours that individual services are being provided, including evenings and weekends.Discussion: OMHSAS suggests that IBHS agencies have policies and procedures in place to make sure a supervisor is available for consultation with staff during all hours when individual services are being provided. OMHSAS interprets the term “available” to mean that the supervisor should be able to be reached during hours services are provided.  Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, staff schedules, on call schedules as applicable, and may interview staff as needed to determine compliance with this section of the regulation. Primary Benefit: To ensure that supervisory support is available during the hours when services are being provided.

Regulation: § 5240.73. Training requirements for staff who provide individual services.(a)  An IBHS provider that provides individual services shall ensure that staff complete initial and annual training requirements.Discussion: OMHSAS suggests that IBHS providers develop policies to track and monitor the completion of trainings to ensure requirements are met. It is recommended that IBHS agencies should retain physical copies or printouts of training certificates to demonstrate that an individual has completed training.OMHSAS suggests that IBHS agencies should keep a record of training in each staff member’s personnel files instead of a provider-wide record devoted to training because training files must be retained for at least 4 years after staff member is no longer employed with the provider per § 5240.42(b)(2). Otherwise, IBHS agencies must develop policies and procedures to assure that training records of staff who no longer are employed are kept for this timeframe. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, and all initial and annual training documentation, and training tracking documents to determine the requirements of this section of the regulation are met. Primary Benefit: To ensure initial and annual training requirements are met.

Regulation: § 5240.73. Training requirements for staff who provide individual services.(b)  An individual who provides behavior consultation services or mobile therapy services shall complete at least 16 hours of Department-approved training annually that is related to the individual’s specific job functions and is in accordance with the individual training plan required under §  5240.13 (relating to staff training plan).Discussion: The timeframe an IBHS provider uses to determine a staff member meets annual training requirements should be clearly indicated in the provider’s training policies and procedures. These timeframes may include, but are not limited to, calendar year, fiscal year, and annual range from date of hire.The process to submit trainings for Department approval, and lists of trainings that do not require Department review and approval are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, training records, and individual training plans to determine the requirements of this section of the regulation are met. Primary Benefit: To ensure that staff receive trainings relevant to the populations served and to ensure staff are qualified.

Regulation: § 5240.73. Training requirements for staff who provide individual services.(c)  If the individual has not previously provided BHT services, the individual shall complete at least 30 hours of Department-approved training prior to providing services independently that includes the following topics:   (1)  Sections 6301—6386 of 23 Pa.C.S. (relating to Child Protective Services Law) and mandated reporting requirements.   (2)  Crisis intervention skills, including risk management, de-escalation techniques and safety planning.   (3)  Behavior management skills and coaching.   (4)  Child and adolescent development.   (5)  Overview of serious emotional disturbance and other behavioral and psychosocial needs of the children, youth and young adults with whom the individual works.   (6)  Professional ethics, conduct and confidentiality.   (7)  First aid, universal precautions and safety.   (8)  Psychotropic medications, including common side effects.Discussion: OMHSAS interprets this section of the regulation to apply to BHTs and BHT-ABAs. Graduate level staff who have not previously provided BHT services are not required to complete these trainings.Depending on the type of services provided, it is possible that an IBHS provider employs BHT-level staff who never provide services independently. In such cases, the IBHS provider should create a policy and procedure that outlines the manner and timeframe in which the topics outlined in this section will be provided. This policy and procedure should be provided to the OMHSAS Licensing Representative for review.OMHSAS suggests that IBHS agencies have a standardized training provider developed for newly hired BHTs without prior experience, to assure that all required content is met. In order to verify that the initial training requirements are met, the IBHS provider should document the date of initial independent service provided by a newly hired BHT without prior experience providing BHT services. A mandated reporter training completed prior to hire may be considered towards the training requirement under § 5240.73(c)(1), as long as the training is valid on the date of hire. The mandated reporter training is valid for a period of 5 years. An individual who completed a 40-hour RBT Task List training (even if it was completed prior to hire at the IBHS provider) may count corresponding content areas of that training that align with the requirements toward the 30 hours of training needed prior to working independently.OMHSAS has interpreted that both first aid and cardiopulmonary resuscitation (CPR) are inherent within “first aid, universal precautions and safety” under § 5240.73(c)(7) of the IBHS regulations. Certification demonstrates that the individual has learned acceptable techniques.§ 5240.73(c)(7) also addresses safety.  OMHSAS acknowledges that it may be necessary for an IBHS agency to store life-saving medications at a licensed location based on the specific needs of the individuals served. Quick and easy access to life-saving medications is permitted without the requirement of it being locked.  It is recommended that a prescription from a physician be kept in the applicable records or documentation of a specific allergy that supports the need to keep emergency life-saving medications on site. Some examples would be EpiPens to treat an anaphylactic reaction or a medication to address a seizure. These would be medications that needs to go with a child (or quickly accessible by any adult who is responsible for the child at any given time.  EpiPens and inhalers are not controlled medications, so they do not need double-locked, but would need to be accessed quickly enough to be administered in an emergency situation.  OMHSAS suggests that staff are trained on any and all emergency medications that will be kept on site including the purpose of the medication and how it should be administered.The process to submit trainings for Department approval, and lists of trainings that do not require Department review and approval are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review staff training records (including trainings completed prior to hire date), and documentation that shows the date the BHT began providing services to determine compliance with this section of the regulation. Primary Benefit: To ensure that staff are trained in techniques and subject matters that are important to the independent provision of BHT services prior to provision of services independently.

Regulation: § 5240.73. Training requirements for staff who provide individual services.(d)  If an individual has not previously provided BHT services, the individual shall complete at least 24 hours of Department-approved training within the first 6 months of providing BHT services that includes the following topics:   (1)  Documentation skills.   (2)  Systems of care principles.   (3)  Overview of functional behavioral assessment.   (4)  Ethnic, cultural and linguistic considerations of the community served.   (5)  Strategies and interventions to engage children, youth or young adults and parents, legal guardians or caregivers in services, including family systems theory.   (6)  Skills and techniques for working with families.   (7)  Overview of community resources and child and youth-serving systems and processes.   (8)  Cross-systems collaboration.   (9)  Communication and conflict resolution skills.   (10)  Basic individual education plan and special education information.   (11)  Safe use of restrictive procedures in accordance with § 5240.6 (relating to restrictive procedures).Discussion: OMHSAS interprets this section of the regulation to only apply to BHTs and BHT-ABAs, graduate level staff who have not previously provided BHT services are not required to complete these trainings.OMHSAS suggests that IBHS agencies have a standardized training provider developed for newly hired BHTs without prior experience, to assure that all required content is met. Because 24 hours of training are required within the first 6 months of providing BHT services, if service provision does not begin at hire the IBHS provider should document the date when the BHT first provides IBHS services. An individual who completed a 40-hour RBT Task List training (even if it was completed prior to hire at the IBHS provider) may count corresponding content areas of that training that align with the requirements toward the 30 hours of training needed prior to working independently.The process to submit trainings for Department approval and lists of trainings that do not require Department review/approval are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review staff training records (including trainings completed prior to hire date), and the program information form to determine compliance with this section of the regulation. Primary Benefit: To ensure that staff have been sufficiently trained in topics relevant to their job functions within the first six month of provision of BHT services.

Regulation: § 5240.73. Training requirements for staff who provide individual services.(e)  An individual who provides BHT services shall complete at least 20 hours of Department-approved training annually that is related to the individual’s specific job functions and is in accordance with the individual training plan required under § 5240.13.Discussion: The timeframe an IBHS provider uses to determine a staff member meets annual training requirements should be clearly indicated in the provider’s training policies and procedures. These timeframes may include, but are not limited to, calendar year, fiscal year, and annual range from date of hire. The process to submit trainings for Department approval and lists of trainings that do not require Department review/approval are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, training records, and individual training plans to determine the requirements of this section of the regulation are met. Primary Benefit: To ensure that staff receive sufficient training connected to their job functions on an annual basis.

Regulation: § 5240.73. Training requirements for staff who provide individual services.(f)   An individual who provides BHT services may substitute completed college coursework for required training topics in subsection (c) or (d) by providing an official transcript and other documentation to the IBHS provider that reflects that the coursework addressed a required training topic.Discussion: OMHSAS suggests IBHS agencies that accept completed college coursework in place of required training topics have a policy and procedure that outlines the approval of completed college coursework and the process to determine the relevant training topics that the coursework covered. OMHSAS has provided guidance that one credit hour equals one training hour. A provider’s policy and procedure should be reviewed by the OMHSAS Licensing Representative.Although not addressed in this section of the regulation, OMHSAS will allow IBHS agencies to also accept completed college coursework for annual training requirements, but it may only be counted towards training requirements one time. Inspection Procedures: OMHSAS Licensing Representatives will review staff records, training records, transcripts, and policies and procedures to determine compliance with this section of the regulation. Primary Benefit: To allow newly hired BHTs who have completed coursework required in this regulation to apply the content they studied towards initial training requirements.

Regulation: § 5240.73. Training requirements for staff who provide individual services.(g)  An individual who is certified may count hours of training required to maintain certification towards the training requirement in subsections (b)—(e).Discussion: OMHSAS suggests that IBHS agencies that accept certification in lieu of required training topics have a policy and procedure that outlines the approval of the certification and the process to determine the relevant training topics that the certification covered. This policy and procedure should be reviewed by the OMHSAS Licensing Representative. Inspection Procedures: OMHSAS Licensing Representatives will review staff records, training records, certification, and policies and procedures to determine compliance with this section of the regulation. Primary Benefit: To allow newly hired staff who are certified to apply the knowledge which was required for certification to count towards initial training requirements.

Regulation: § 5240.73. Training requirements for staff who provide individual services.(h)  An individual who is licensed in this Commonwealth may count hours of training required to maintain licensure towards the training requirements in subsections (b)—(e).Discussion: OMHSAS suggests that IBHS agencies that accept licenses in lieu of required training topics have a policy and procedure that outlines the approval of the license and the process to determine the relevant training topics that the license covered. This policy and procedure should be reviewed by the OMHSAS Licensing Representative. Inspection Procedures: OMHSAS Licensing Representatives will review staff records, training records, licenses, and policies and procedures to determine compliance with this section of the regulation. Primary Benefit: To allow newly hired staff who are licensed to apply the knowledge which was required for licensure to count towards initial training requirements.

Regulation: § 5240.74. Individual services initiation requirements.(a)  An IBHS provider shall provide individual services to a child, youth or young adult in accordance with a written order under § 1155.32(a)(1) (relating to payment conditions for individual services).Discussion: Although Chapter 1155 outlines medical assistance payment conditions for IBHS, all agencies that provide individual IBHS must have a written order that meets the requirements of § 1155.32(a)(1) to initiate IBHS individual services. The IBHS provider must provide services in accordance with the written order. OMHSAS interprets the regulation to mean that if an assessment of the child, youth or young adult’s needs determines more service hours are required than are included in the written order, the original written order must be amended or a new written order must be created. If an assessment determines that less hours than the number included in the written order is needed, no change to the written order is necessary.  § 1155.32(a)(1) requires a written order for services based on face-to-face interaction with the child, youth or young adult that meets the following:     (i)   Written within 12 months prior to the initiation of IBHS.     (ii)   Written by a licensed physician, licensed psychologist, certified registered nurse     practitioner or other licensed professionals whose scope of practice includes the  diagnosis and treatment of behavioral health disorders and the prescribing of  behavioral health services, including IBHS.     (iii)   Includes a behavioral health disorder diagnosis listed in the most recent edition of the DSM or ICD.     (iv)   Orders one or more IBHS for the child, youth or young adult and includes the following:       (A)   The clinical information to support the medical necessity of the service ordered.       (B)   The maximum number of hours of each service per month.       (C)   The settings where services may be provided.       (D)   The measurable improvements in the identified therapeutic needs that indicate when services may be reduced, changed or terminated.§ 1155.32(a)(1)(iv)(B)-(C) states a written order must include the maximum hours of each service per month and the setting where services may be provided. This requirement is interpreted by OMHSAS to mean that the written order minimally must identify the settings where services are to be provided (home, school, community, center) and the maximum number of hours per month for each service (Individual, ABA, Group, EBT). Accordingly, the intent of the written order is to provide the settings where services may be provided. Therefor an evaluator may say, for example, “30 hours in the home, school and community”, or “20 hours in the school and 10 hours in the home and community”. The assessment will capture the specific number of hours needed in each setting and must not be in conflict with the written order.Providers that wish to utilize telehealth to complete the written order are able to do so as long as they meet the requirements outlined in Bulletin OMHSAS-22-02 Revised Guidelines for the Delivery of Behavioral Health Services Through Telehealth provided updated guidance on behavioral health services provided through telehealth. The use of audio-only telehealth would not meet the requirement of face-to-face as per § 1155.32(a)(1).    Inspection Procedures: OMHSAS Licensing Representatives will review the written order and the individual records to ensure services are provided in accordance with the written order to determine compliance with this section of the regulation. Primary Benefit: To ensure services are provided in accordance with the written order as this provides documentation that the services are medically necessary and provides the framework of the therapeutic services the child requires.

Regulation: § 5240.74. Individual services initiation requirements. (b)  Prior to the initiation of individual services, the IBHS provider shall obtain written consent to receive the individual services identified in the written order from the youth, young adult or parent or legal guardian of a child or youth.Discussion: OMHSAS suggests that the consent to receive services either includes the recommendation(s) found in the written order or refers the family to the written order. This way, their consent to those specified services is documented. For the purpose of required timing, OMHSAS interprets the initiation of services as the first day an individual service is provided. This includes the first day an assessment is conducted. Inspection Procedures: OMHSAS Licensing Representatives will review the consent form and individual record documents to identify the date of the initiation of services to determine compliance with this section of the regulation. Primary Benefit: To ensure that the youth, young adult or parent or legal guardian are consenting to the services outlined in the written order prior to the initiation of these services.

Regulation: § 5240.75. Individual services provision. (a)  Behavior consultation services consist of clinical direction of services to a child, youth or young adult; development and revision of the ITP; oversight of the implementation of the ITP and consultation with a child’s, youth’s or young adult’s treatment team regarding the ITP.Discussion: BC services are focused on behavior and does not including counseling work.Because only those who meet the qualifications to provide BC and MT services may conduct an individual assessment, OMHSAS interprets the term “clinical direction of services” to include conducting assessments. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, supervision records, and individual records including individual treatment plans, progress notes, and other relevant records to determine compliance with this section of the regulation. OMHSAS Licensing Representatives may interview staff as needed. Primary Benefit: To ensure BCs provide individual service provisions as outlined in the regulation.

Regulation: § 5240.75. Individual services provision. (b)  Mobile therapy services consist of individual therapy, family therapy, development and revision of the ITP, assistance with crisis stabilization and assistance with addressing problems the child, youth or young adult has encountered.Discussion: OMHSAS interprets this regulation to mean that MT is focused on talk therapy, but it may include some behavioral therapy as well.Because only those who meet qualifications for BC and MT services may conduct an individual assessment, OMHSAS interprets the term “clinical direction of services” to include conducting assessments. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, supervision records, and individual records including individual treatment plans, progress notes, and other relevant records to determine compliance with this section of the regulation. OMHSAS Licensing Representatives may interview staff as needed. Primary Benefit: To ensure MTs provide individual service provisions as outlined in the regulation.

Regulation: § 5240. 75. Individual services provision. (c)  BHT services consist of implementing the ITP.Discussion: OMHSAS infers from this regulation that the BHT’s implementation of the ITP should be under the direction of someone who meets the qualifications of an IBHS supervisor. Services provided by the BHT may include the collection of data and implementation of interventions as guided by the treatment team lead and outlined in the ITP. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, supervision records, and individual records including individual treatment plans, progress notes, collected data, and other relevant records to determine compliance with this section of the regulation. OMHSAS Licensing Representatives may interview staff as needed. Primary Benefit: To ensure BHTs provide individual service provisions as outlined in the ITP.

Regulation: § 5240.75. Individual services provision. (d)  An individual who provides BHT services may not provide interventions requiring skills, experience, credentials or licensure that the individual does not possess.Discussion: OMHSAS interprets regulation to mean only BHTs with the required skills, experience, credentials or licensure may provide specialized interventions that have such requirements. For example, interventions related to trauma should only be conducted by BHTs who have the skills, experience, credentials, or licensure needed to provide trauma-focused interventions. It is up to the IBHS provider that provides specialized interventions to understand the requirements that are needed and to document in the BHT’s staffing records how these requirements are met. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, supervision records, training records, HR files, and individual records including individual treatment plans, progress notes, collected data, and other relevant records to determine compliance with this section of the regulation. OMHSAS Licensing Representatives may interview staff as needed. Primary Benefit: To ensure BHTs have necessary training, education, skills, experience and credentials to provide interventions as outlined in applicable ITPs.

APPLIED BEHAVIOR ANALYSIS

Regulation: § 5240.81. Staff qualifications for ABA services. (a)  An administrative director of an IBHS provider that provides ABA services shall meet one of the following:   (1)  Have a bachelor’s degree in ABA, psychology, social work, counseling, education, public administration, business administration or related field from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.   (2)  The qualifications for a clinical director in subsection (b).Discussion: OMHSAS interprets regulation to mean an individual can serve as the administrative director of a provider that provides Individual services and/or ABA services and/or Group services as long as they are able to perform:All tasks as outlined in § 5240.11(b) and Meet the requirements outlined in this section Meet the respective qualification requirements of the Individual and/or Group services. § 5240.12(a) outlines qualification requirements of an administrative director that differ from requirements outlined in this section.Agencies are encouraged to search the United States Department of Education and/or the Council for Higher Education Accreditation websites to verify the college or university is accredited. Even though a college may sound familiar, diploma mills have been known to use familiar colleges by changing the name slightly so that it appears familiar. There are not only fake colleges, but fake accreditation counsels. Therefore, a provider may need to verify the accrediting provider through one of the referenced provider websites. It should be noted that the Department of Education does not keep historical information on its website. In the case of Pennsylvania colleges that have gone from State Colleges to Universities, the State college information is not kept in the database.It is a recommended by OMHSAS to verify a person’s education through college transcripts. Transcripts are sent directly to a hiring provider and not the individual and contain a seal as well as the accrediting provider name. College diplomas may be forged easier than transcripts. Transcripts also provide course names which assist in verifying number of hours in a particular curriculum.  Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, job descriptions, credentials, educational transcripts/degrees and trainings, and may search the USDE or CHEA website to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review credentials for all new staff during initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure that only qualified staff fill this role.

Regulation: § 5240.81. Staff qualifications for ABA services.(c)  By July 1, 2022, a clinical director of an IBHS provider that provides ABA services shall meet one of the following:   (1)  Be licensed in this Commonwealth as a physician practicing psychiatry, psychologist, certified registered nurse practitioner, professional counselor, marriage and family therapist, clinical social worker, behavior specialist, social worker or other professional with a scope of practice that includes overseeing the provision of ABA services and have a certification as a BCBA or other graduate-level certification in behavior analysis that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute and a minimum of 2 years of experience in providing ABA services.   (2)  Be licensed in this Commonwealth as a psychologist and have a minimum of 5 years of full-time experience providing clinical oversight of an ABA provider and a minimum of 40 hours of training related to ABA approved by the Department or provided by a continuing education provider approved by the Behavior Analyst Certification Board.   (3)  Be licensed in this Commonwealth as a psychologist and have a graduate degree or graduate certificate in ABA from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or have an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency. Discussion: OMHSAS interprets regulation to mean that as of July 1, 2022, clinical directors must meet the requirements outlined in this section. Those who were hired under the qualifications found in § 5240.81(b) prior to July 1, 2022, should on this date meet these qualifications to continue in the role of a clinical director. Those who do not qualify with the requirements of this section on July 1, 2022 may not continue as a clinical director for ABA services without an approved waiver from the Department.  An individual can serve as the clinical director of a provider that provides Individual services and/or ABA services and/or Group services as long as they are able to perform all tasks as outlined in § 5240.11(d) and meet the requirements outlined in this section and the respective qualification requirements of the ABA or Group services. § 5240.12(b) outlines qualification requirements of a clinical director that differ from requirements outlined in this section. Agencies are encouraged to search the United States Department of Education and/or the Council for Higher Education Accreditation websites to verify the college or university is accredited. Even though a college may sound familiar, diploma mills have been known to use familiar colleges by changing the name slightly so that it appears familiar. There are not only fake colleges, but fake accreditation counsels. Therefore, a provider may need to verify the accrediting provider through one of the referenced provider websites.  It should be noted that the Department of Education does not keep historical information on its website. In the case of Pennsylvania colleges that have gone from State Colleges to Universities, the State college information is not kept in the database. It is a recommended by OMHSAS to verify a person’s education through college transcripts. Transcripts are sent directly to a hiring provider and not the individual and contain a seal as well as the accrediting provider name. College diplomas may be forged easier than transcripts. Transcripts also provide course names which assist in verifying number of hours in a particular curriculum.  A provider may count the part-time experience as part of the experience required to be a clinical director. To meet qualification requirements under § 5240.81(c)(1), part-time experience providing ABA services must be equivalent to 2 years of full-time experience. To meet qualification requirements under § 5240.81(c)(2), part-time experience providing clinical oversight of an ABA provider must be equivalent to 5 years of full-time experience. Inspection Procedures: Following July 1, 2022, OMHSAS Licensing Representatives will review the program information from job descriptions, credentials, educational transcripts/degrees and trainings, and may search the USDE or CHEA website to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review credentials for all new Clinical Directors during initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure that only qualified staff fill this role.

Regulation: § 5240.81. Staff qualifications for ABA services. (d)  Individuals who provide ABA services through behavior analytic services shall be licensed in this Commonwealth as a psychologist, professional counselor, marriage and family therapist, clinical social worker, social worker, behavior specialist, certified registered nurse practitioner or a professional with a scope of practice that includes overseeing the provision of ABA services and have a certification as a BCBA or other graduate-level certification in behavior analysis that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.Discussion: Currently, the only graduate-level certification in behavior analysis available is the BCBA certification. The Department included language about other graduate-level certifications as a placeholder should other accredited certifications for behavior analysis be developed. Individuals who have completed the coursework to sit for the BCBA exam but have not yet passed the exam do not have a graduate-level certification in behavior analysis.  Inspection Procedures: OMHSAS Licensing Representatives will review the program information from job descriptions, credentials, educational transcripts/degrees, training documents, and may search the USDE or CHEA website to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review credentials for all new BA staff during initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure that only qualified staff fill this role.

Regulation: § 5240.81. Staff qualifications for ABA services. (e)  Individuals who provide ABA services through behavior consultation—ABA services shall meet one of the following:   (1)  Be licensed in this Commonwealth as a psychologist, professional counselor, marriage and family therapist, clinical social worker, social worker, behavior specialist, certified registered nurse practitioner or a professional with a scope of practice that includes overseeing the provision of ABA services and have one of the following:     (i)     A certification as a BCaBA or other undergraduate-level certification in behavior analysis that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.     (ii)    A minimum of 1 year of full-time experience providing ABA services and a minimum of 12 credits in ABA from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or the equivalent from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services.     (iii)   A minimum of 1 year of full-time experience providing ABA services under the supervision of a professional with a certification as a BCBA or other graduate-level certification in behavior analysis that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute and a minimum of 40 hours of training related to ABA approved by the Department or provided by a continuing education provider approved by the Behavior Analyst Certification Board.   (2)  Be licensed in this Commonwealth as a psychologist and have a minimum of 1 year of full-time experience providing ABA services and a minimum of 40 hours of training related to ABA approved by the Department or provided by a continuing education provider approved by the Behavior Analyst Certification Board.Discussion: OMHSAS interprets regulation to mean that the certification requirement outlined in § 5240.81(e)(1)(i) may minimally be met by a BCaBA certification, and may also be met by a BCBA certification. The 1 year full-time experience requirement outlined in § 5240.81(e)(1)(ii) and § 5240.81(e)(1)(iii) may be met by counting part-time experience that is equivalent to a year of full-time experience.The requirement that an individual has experience under the supervision of a certified professional, outlined in § 5240.81(e)(1)(iii), included language about other graduate-level certifications as a placeholder should other accredited certifications for behavior analysis be developed.  The 40 hours of training related to ABA, which is outlined in § 5240.81(e)(1)(iii) and § 5240.81(e)(2) may be met by completing a 40-hour RBT training provider if the RBT training provider is provided by a continuing education provider that is approved by the Behavior Analyst Certification Board. A certificate of completion is sufficient documentation to demonstrate that an individual has completed an ACE-approved training. Additionally, the 40 hours of training related to ABA, which is outlined in § 5240.81(e)(1)(iii) and § 5240.81(e)(2), may be met with coursework completed through an approved BCBA or BCaBA course verified course sequence or degree provider. One coursework credit hour is equal to one training hour. Staff that can document that they completed 40 hours of training related to ABA as part of the training required to obtain licensure would not need an additional 40 hours of training related to ABA to qualify under § 5240.81(e)(1)(iii) and § 5240.81(e)(2). Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, job descriptions, licenses, credentials, educational transcripts/degrees and trainings, and may search the USDE or CHEA website to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review credentials for all new BC-ABA staff during initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure that only qualified staff fill this role.

Regulation: § 5240.81. Staff qualifications for ABA services.(f)  Individuals who provide ABA services through assistant behavior consultation—ABA services shall meet one of the following:   (1)  Have the qualifications for licensure as a behavior specialist under 49 Pa. Code § 18.524 (relating to criteria for licensure as behavior specialist) except the experience required under section 18.524(c).   (2)  Have a certification as a BCaBA or other undergraduate-level certification in behavior analysis that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute and a bachelor’s degree in psychology, social work, counseling, education or related field from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.   (3)  Have a minimum of 6 months of experience in providing ABA services and a bachelor’s degree in psychology, social work, counseling, education or related field and a minimum of 12 credits in ABA from a college or university accredited by an provider recognized by the United States Department of Education or the Council for Higher Education Accreditation or the equivalent from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.Discussion: OMHSAS interprets this regulation to mean the following: in order for an individual to qualify as an Assistant BC-ABA under § 5240.81(f)(1), the IBHS provider should document that the staff member meets the below requirements for licensure as a behavior specialist under 49 Pa. Code § 18.524: (a) An applicant for licensure as a behavior specialist shall satisfy the Board that the applicant is of good moral character and has received a master’s or higher degree from a Board-approved, accredited college or university, including a major course of study in at least one of the following:(1) School, clinical, developmental or counseling psychology.(2) Special education.(3) Social work.(4) Speech therapy.(5) Occupational therapy.(6) Professional counseling.(7) Behavioral analysis.(8) Nursing.(9) Another related field. (b) An applicant for licensure as a behavior specialist shall have at least 1 year of experience involving functional behavior assessments of individuals under 21 years of age, including the development and implementation of behavioral supports or treatment plans. (d) An applicant for licensure as a behavior specialist shall have completed 90 hours of course work in evidence-based practices from an accredited college or university or training approved by the BACB or the BAS as follows:(1) Three hours of professional ethics approved by the BAS.(2) Eighteen hours of autism-specific coursework or training.(3) Sixteen hours of assessments coursework or training.(4) Sixteen hours of instructional strategies and best practices.(5) Eight hours of crisis intervention.(6) Eight hours of comorbidity and medications.(7) Five hours of family collaboration.(8) Sixteen hours of addressing specific skill deficits training. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, job descriptions, credentials, educational transcripts/degrees and trainings, documentation verifying the requirements of 49 Pa. Code § 18.524(a)(b)(d), and may search the United States Department of Education or Council for Higher Education Accreditation website to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review credentials for all new Asst BC-ABA staff during initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure that only qualified staff fill this role.

Regulation: § 5240.81. Staff qualifications for ABA services.(g)  By July 1, 2020, individuals who provide ABA services through BHT-ABA services shall meet one of the following:   (1)  Have a certification as a BCaBA.   (2)  Have a certification as an RBT.   (3)  Have a certification as a BCAT.   (4)  Have a behavior analysis certification from an organization that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.   (5)  Have a high school diploma or the equivalent of a high school diploma and have completed a 40-hour training covering the RBT Task List as evidenced by a certification that includes the name of the responsible trainer, who is certified as a BCBA or BCaBA.   (6)  Have a minimum of 2 years of experience in providing ABA services and a minimum of 40 hours of training related to ABA approved by the Department or provided by a continuing education provider approved by the Behavior Analyst Certification Board.Discussion: OMHSAS interprets this regulation to mean that IBHS agencies may hire individuals who are not yet qualified to provide BHT services because they lack the certifications required under § 5240.81(g)(1)-(4), or lack the 40-hour training covering the RBT Task List required under § 5240.81(g)(5), or lack the 40 hours of training related to ABA required under § 5240.81(g)(6), in order to allow training or certification to be obtained while employed at the provider. However, IBHS services may not be provided by these individuals until they meet one of the qualifications of this section of the regulation. Such IBHS agencies should have a process to verify that no staff provides services prior to when the qualifications are met.The “40-hour training covering the RBT Task List” required under § 5240.81(g)(5) is issued by the individual BCBA or BCaBA certified trainer responsible for the training that confirms that the 40-hour RBT training was completed.The “2 years of experience in the provision of ABA services” required under § 5240.81(g)(6) includes any position that implemented ABA services. While general experience working in a pre-school or daycare would not be considered ABA experience, implementing ABA services while a child was in a pre-school or daycare setting would be considered ABA service experience. For staff members who are qualified under § 5240.71(d)(5), when the staff member has attained 2 years of experience in the provision of behavioral health services, they may be deemed qualified under § 5240.71(d)(6). This may be important to track for IBHS agencies because there are less stringent supervision requirements for staff members who are qualified under § 5240.71(d)(6). Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, job descriptions, credentials, educational transcripts/degree and trainings, and may search the USDE or CHEA website to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review credentials for all new BHT-ABA staff during initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure that only qualified staff fill this role.

Regulation: § 5240.82. Supervision of staff who provide ABA services.(a)  An individual who meets the qualifications of a clinical director shall provide the following supervision to individuals who provide behavior analytic services and behavior consultation—ABA services:   (1)  One hour of individual face-to-face supervision per month that includes oversight of the following:     (i)     The interventions being implemented.     (ii)    The child’s, youth’s or young adult’s progress towards the goals of the ITP.     (iii)   Consideration of adjustments needed to the ITP.     (iv)   The staff person’s skills in implementing the interventions in the ITP.   (2)  If the individual who provides behavior analytic services or behavior consultation—ABA services supervises an individual who provides assistant behavior consultation—ABA services or BHT-ABA services, the individual shall receive an additional hour of face-to-face supervision per month that includes a discussion of the assistant behavior consultation—ABA services or BHT-ABA serviced being provided.   (3)  Thirty minutes of direct observation of services being provided every 6 months.Discussion: OMHSAS interprets regulation to mean that any individual who meets the qualifications of a clinical director for ABA services can provide supervision to individuals who provide BA and BC-ABA services. It is up to the provider to decide how to utilize individuals who meet the qualifications of a clinical director to meet the supervision requirements. However, the clinical director is ultimately responsible for ensuring that staff who provide BA and BC-ABA services are supervised in accordance with the IBHS regulations. If a clinical director provides BA or BC-ABA services, OMHSAS suggests that they should make arrangements to have peer supervision by an individual who meets the qualifications of a clinical director for ABA services. If a clinical director for ABA services does not typically provide BA or BC-ABA services but will provide these services when an individual who normally provides these services is unavailable, the IBHS provider should develop a policy and procedure to outline the circumstances when the clinical director will provide services and how the clinical director will seek peer supervision to cover the period when the clinical director is providing services. At a minimum, this should include the name of the individual who will conduct the peer supervision, confirmation that the individual who provides peers supervision meets the qualification of a clinical director for ABA services, and the method, frequency, and duration of the supervision. The policy and procedure will be reviewed by OMHSAS as part of licensing. The additional hour of supervision required under § 5240.82(a)(2) is not necessary for a clinical director who is supervising staff, nor is there a requirement that the peer providing supervision of the clinical director sign off on any documents in the individual records. The hour(s) of supervision required may be a combination of shorter-length supervision sessions that add up to the required timeframe. The additional hour of supervision under § 5240.82(a)(2) (required because the BA or BC-ABA supervises an individual who provides BHT-ABA services), may be provided through group supervision as long as the BA or BC-ABA receives one hour of individual face-to-face supervision.When a staff member provides multiple types of IBHS services, they should receive supervision related to each IBHS service they deliver. However, there is no need to supervise the service provision separately because supervision related to multiple types of IBHS can occur concurrently. For example, staff who provide both MT and BC-ABA can receive a total of 1 hour of supervision per month which covers both services rather than receiving separate 1 hour per month supervision addressing MT services and another 1 hour per month supervision addressing BC-ABA services. If there are different supervision requirements, staff providing multiple types of IBHS should receive the highest amount of supervision required for the IBHS the staff person provides. Supervision of staff providing multiple types of IBHS must be conducted by a qualified supervisor.  A supervisor is qualified if they are permitted to conduct the supervision of each of the services provided by the staff member under the IBHS regulation. The IBHS regulations require direct observation to occur while staff is providing services directly to the child, youth or young adult. As a result, observing a staff person who provides BA or BC-ABA conduct a treatment team meeting would not count as direct observation. Observing staff conduct a treatment team meeting could be considered supervision.As outlined in § 5240.72(f), documentation of supervision must be included in the supervised staff member’s personnel file. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures for clinical director supervision when the clinical director provides IBHS services, to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review supervision documentation for all new BA or BC-ABA staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure regular supervision and direct observation for all BA and BC-ABA staff to maintain quality of care.

Regulation: § 5240.82. Supervision of staff who provide ABA services.(b)  An individual who meets the qualifications of a clinical director or is qualified to provide behavior analytic services or behavior consultation—ABA services shall provide the following supervision to individuals who provide assistant behavior consultation—ABA services:   (1)  One hour of supervision two times a month. The supervision must be face-to-face and include only the individual being supervised and the supervisor.   (2)  If the individual has not previously provided assistant behavior consultation—ABA services, 3 hours of onsite supervision during the provision of ABA services to a child, youth or young adult prior to providing ABA services independently.   (3)  Thirty minutes of direct observation of the provision of ABA services to a child, youth or young adult during the implementation of the ITP every 6 months.   (4)  The supervision must include oversight of the following:     (i)     The interventions being implemented.     (ii)    The child’s, youth’s or young adult’s progress towards the goals of the ITP.     (iii)   Consideration of adjustments needed to the ITP.     (iv)   The staff person’s skills in implementing the interventions in the ITP.Discussion: OMHSAS interprets regulation to mean that any individual who meets the qualifications of a clinical director, or who is qualified to provide BA or BC-ABA services, can provide supervision to staff members who provide Assistant BC-ABA services. It is up to the provider to decide how to utilize individuals who meet these qualifications to meet the supervision requirements. However, the clinical director is ultimately responsible for ensuring that staff who provide IBHS are supervised in accordance with the IBHS regulations.The hour(s) of supervision required may be met by a combination of shorter-length supervision sessions that add up to the required timeframe. In order to verify the requirements of § 5240.82(b)(2) for newly hired Assistant BC-ABA staff members who have not previously provided BHT services, OMHSAS suggests that the IBHS provider document the date when the Assistant BC-ABA staff begins providing services independently. Direct observation is not counted towards the required hours of supervision. However, it is required in addition to the required hours of supervision. When a staff member provides multiple types of IBHS services, they should receive supervision related to each IBHS service they deliver. However, there is no need to supervise the service provision separately because supervision related to multiple types of IBHS can occur concurrently. For example, staff who provide both BC and Assistant BC-ABA services can receive a total of 1 hour of supervision per month which covers both services rather than receiving separate 1 hour per month supervision addressing BC services and another 1 hour per month supervision addressing Assistant BC-ABA services. If there are different supervision requirements, staff providing multiple types of IBHS should receive the highest amount of supervision required for the IBHS the staff person provides. Supervision of staff providing multiple types of IBHS must be conducted by a qualified supervisor.  A supervisor is qualified if they are permitted to conduct the supervision of each of the services provided by the staff member under the IBHS regulation. The Department expects that there will be a need for supervision to occur outside of the presence of the child, youth or young adult. For example, a supervisor may need to discuss feedback with an individual providing BHT services or BHT-ABA services which may not be appropriate to discuss in front of the child, youth, young adult or caregiver.As outlined in § 5240.72(f), documentation of supervision must be included in the supervised staff member’s personnel file. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures and any other relevant documentation to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review supervision documentation for all new Asst. BC-ABA staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure regular supervision and direct observation for Assistant BC-ABA staff to maintain quality of care.

Regulation: § 5240.82. Supervision of staff who provide ABA services.(c)  An individual who meets the qualifications of a clinical director or is qualified to provide behavior analytic services or behavior consultation—ABA services or an individual who is qualified to provide assistant behavior consultation—ABA services and has a BCaBA or other undergraduate-level certification in behavior analysis that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute shall provide the following supervision to individuals who provide BHT-ABA services:   (1)  One hour of supervision each week if the individual who provides BHT-ABA services works at least 37.5 hours per week or 1 hour of supervision two times a month if the individual who provides BHT-ABA services works less than 37.5 hours a week. An individual who provides BHT-ABA services must receive 1 hour of individual face-to-face supervision each month.   (2)  If the individual has not previously provided BHT-ABA services, 6 hours of onsite supervision during the provision of ABA services to a child, youth or young adult prior to providing ABA services independently.   (3)  One hour of direct observation of the provision of ABA services to a child, youth or young adult during the implementation of the ITP every 4 months, unless the individual meets the qualifications to provide BHT-ABA services included in §  5240.81(g)(5) (relating to staff qualifications for ABA services). If the individual meets the qualifications to provide BHT-ABA services included in §  5240.81(g)(5), the individual shall receive 1 hour of direct observation of the provision of ABA services to a child, youth or young adult during the implementation of the ITP every 2 months.   (4)  The supervision must include oversight of the following:     (i)     The interventions being implemented.     (ii)    The child’s, youth’s or young adult’s progress towards the goals of the ITP.     (iii)   Consideration of adjustments needed to the ITP.     (iv)   The staff person’s skills in implementing the interventions in the ITP.Discussion: OMHSAS interprets regulation to mean that any individual who meets the qualifications of a clinical director, or who is qualified to provide BA services or BC-ABA services, or is qualified to provide Assistant BC-ABA services and has a BCaBA, can provide supervision to a staff member who provides BHT-ABA services. It is up to the provider to decide how to utilize individuals who meet these qualifications to meet the supervision requirements. However, the clinical director is ultimately responsible for ensuring that staff who provide IBHS are supervised in accordance with the IBHS regulations.The 37.5 hours per week requirement used to determine the frequency of supervision includes all time the individual works, including hours the individual is not providing face-to-face BHT/BHT-ABA services.The hour(s) of supervision required may be met by a combination of shorter-length supervision sessions that add up to the required timeframe. In order to verify the requirements of § 5240.82(c)(2) for newly hired BHT-ABA staff members who have not previously provided BHT/BHT-ABA services, the IBHS provider should document the date when the BHT-ABA staff begins providing services independently. Direct observation is not counted towards the required hours of supervision. However, it is required in addition to the required hours of supervision. When a staff member provides multiple types of IBHS services, they should receive supervision related to each IBHS service they deliver. However, there is no need to supervise the service provision separately because supervision related to multiple types of IBHS can occur concurrently. For example, staff who provide both BHT and BHT-ABA can receive a total of 1 hour of supervision per month which covers both services rather than receiving separate 1 hour per month supervision addressing BHT services and another 1 hour per month supervision addressing BHT-ABA services. If there are different supervision requirements, staff providing multiple types of IBHS should receive the highest amount of supervision required for the IBHS the staff person provides. Supervision of staff providing multiple types of IBHS must be conducted by a qualified supervisor.  A supervisor is qualified if they are permitted to conduct the supervision of each of the services provided by the staff member under the IBHS regulation. The Department expects that there will be a need for supervision to occur outside of the presence of the child, youth or young adult. For example, a supervisor may need to discuss feedback with an individual providing BHT services or BHT-ABA services which may not be appropriate to discuss in front of the child, youth, young adult or caregiver.As outlined in § 5240.72(f), documentation of supervision must be included in the supervised staff member’s personnel file. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures and any other relevant documentation to determine compliance with this section of the regulation. OMHSAS Licensing Representatives will review supervision documentation for all new BHT-ABA staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: To ensure regular supervision and direct observation for BHT-ABA staff to maintain quality of care.

Regulation: § 5240.82. Supervision of staff who provide ABA services. (d)  Group supervision may be provided to no more than 12 staff who provide ABA services, but only nine of the staff can provide BHT-ABA services. Discussion: OMHSAS interprets this regulation to mean that a qualified supervisor is permitted to supervise a total of 12 staff members who provide ABA services in a group supervision setting, of which up to 9 may be staff who provide BHT-ABA services. OMHSAS interprets this section of the regulation to mean 12 staff members and not 12 full-time equivalency (FTE) staff members. For example, a supervisor may provide group supervision to 9 BHT-ABAs and 3 BC-ABAs, but a group containing 10 BHT-ABAs and 2 BC-ABAs would not be allowable under the regulation.  IBHS agencies may include staff who provide multiple service types (Individual, ABA, Group, EBT) in group supervision as long as all staff in the group have at least one service type in common. For example, it would be appropriate to include a staff member who provides both Individual and ABA services into group supervision of staff who provide ABA services. However, it would not be appropriate to include a staff member who only provides ABA services into a group comprised of staff members who only provide individual services. A qualified supervisor cannot supervise multiple groups of 12 staff at different times. As outlined in § 5240.82(h), documentation of supervision should be included in the supervised staff member’s personnel file. Therefore, if one group supervision note is created it should be copied and included in all supervised staff members personnel files. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures, personnel files, and any other relevant documentation to determine compliance with this section of the regulation. Primary Benefit: To ensure supervision provided in a group setting is provided in a ratio that allows individualized attention for each staff member.

Regulation: § 5240.82. Supervision of staff who provide ABA services. (e)  An individual may supervise a maximum of 12 full-time equivalent staff who provide ABA services, but only nine of the full-time equivalent staff can provide BHT-ABA services. Discussion: OMHSAS interprets regulation to mean that FTE includes time spent in both direct service provision and non-billable activities related to behavioral health services. When determining if an individual who provides IBHS services works a full-time equivalent, the IBHS provider should include all hours the individual is considered to be working for the IBHS provider, not the specific level of service. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures, personnel files, and any other relevant documentation to determine compliance with this section of the regulation. Primary Benefit: To ensure supervision is provided in a manner that allows individualized supervision.

Regulation: § 5240.82. Supervision of staff who provide ABA services. (f)  A supervisor shall be available to consult with staff during the hours that ABA services are being provided, including evenings and weekends.Discussion: IBHS agencies should have policies and procedures in place to make sure a supervisor is available for consultation with staff during all hours when individual services are being provided. OMHSAS interprets the term “available” to mean that the supervisor should be able to be reached during hours services are provided. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, organizational charts, policies and procedures, staff schedules and other documentation that verifies the availability of the supervisor to determine compliance with this section of the regulation. Primary Benefit: To ensure adequate clinical support is provided to staff providing ABA services.

Regulation: § 5240.82. Supervision of staff who provide ABA services. (g)  Face-to face supervision may be delivered through secure, real-time, two-way audio and video transmission that meets technology and privacy standards required by the Health Insurance Portability and Accountability Act [HIPAA] of 1996 (Pub.L. No. 104-191).Discussion: OMHSAS interprets regulation to mean that face-to-face supervision may include the use of HIPAA-compliant audio-video communication products. Face-to-face supervision may not include supervision conducted using audio-only telephone conversation. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, supervision tracking documents to determine method used for supervision, documentation that verifies any utilized audio-video platform is HIPAA compliant, and the provider’s HIPAA business associate agreement(s) with utilized audio-video platform providers to determine compliance with this section of the regulation. Primary Benefit: To ensure adequate clinical support is provided to staff providing ABA services in a format that protects privacy and security of protected health information.

Regulation: § 5240.82. Supervision of staff who provide ABA services. (h)  A supervisor shall maintain documentation about each supervision session in the supervised staff person’s personnel file that includes the following:   (1)  The date of the supervision session.   (2)  The location and modality of the session, such as in-person or through a secure real-time, two-way audio and video transmission.   (3)  The format of the session, such as individual, group or onsite.   (4)  The start and end time of the supervision session.   (5)  A narrative summary of the points discussed during the session.   (6)  The signature and signature date of the supervisor and the staff person receiving supervision.Discussion: OMHSAS suggests that a record of each supervision session (Individual supervision and, if applicable, Group supervision) should be kept and be considered part of personnel records. IBHS agencies may additionally keep a provider-wide record of each supervision session and supervision tracking documentation outside of personnel records.  Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, and personnel records to determine compliance with this section of the regulation.  Primary Benefit: To ensure that supervision is documented in a standard way with detailed information.

Regulation: § 5240.83. Training requirements for staff who provide ABA services.An IBHS provider that provides ABA services shall ensure that all staff complete initial and annual training requirements.Discussion: OMHSAS suggests that an IBHS provider develop policies to track and monitor the completion of trainings to ensure requirements are met.It is recommended that IBHS agencies should retain physical copies or printouts of training certificates to demonstrate that an individual has completed training.OMHSAS suggests that IBHS agencies should keep a record of training in each staff member’s personnel files instead of a provider-wide record devoted to training because training files must be retained for at least 4 years after staff member is no longer employed with the provider per § 5240.42(b)(2). Otherwise, IBHS agencies should develop policies and procedures to assure that training records of staff who no longer are employed are kept for this timeframe. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, all initial and annual training documentation, and training tracking documents to determine the requirements of this section of the regulation are met. Primary Benefit: To ensure initial and annual training requirements are met.

Regulation: § 5240.83. Training requirements for staff who provide ABA services. (b)  An individual who provides behavior analytic services or behavior consultation—ABA services shall complete at least 16 hours of training annually that is approved by the Department or provided by a continuing education provider approved by the Behavior Analyst Certification Board that is related to the individual’s specific job functions and is in accordance with the individual training plan required under § 5240.13 (relating to staff training plan).Discussion: OMHSAS suggests that the timeframe an IBHS provider uses to determine that a staff member meets annual training requirements be clearly indicated in the provider’s training policies and procedures. These timeframes may include, but are not limited to, calendar year, fiscal year, and annual range from date of hire.The process to submit trainings for Department approval and lists of trainings that do not require Department review are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, training records, and individual training plans to determine the requirements of this section of the regulation are met. Primary Benefit: To ensure that staff receive annual trainings relevant to the populations served and to ensure staff are qualified.

Regulation: § 5240.83. Training requirements for staff who provide ABA services. (c)  An individual who provides assistant behavior consultation—ABA services shall complete the following:   (1)  If the individual does not have a certification as a BCBA, BCaBA, BCAT or other graduate or undergraduate certification in behavior analysis that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, at least 20 hours of training related to ABA that is approved by the Department or provided by a continuing education provider approved by the Behavior Analyst Certification Board before independently providing ABA services to a child, youth or young adult.   (2)  At least 20 hours of training annually that is approved by the Department or provided by a continuing education provider approved by the Behavior Analyst Certification Board that is related to the individual’s specific job functions and is in accordance with the individual training plan required under § 5240.13.Discussion: OMHSAS suggests that the timeframe an IBHS provider uses to determine that a staff member meets annual training requirements be clearly indicated in the provider’s training policies and procedures. These timeframes may include, but are not limited to, calendar year, fiscal year, and annual range from date of hire.For trainings to fulfill the requirement found under § 5240.83(c)(1), they must be related to ABA. Some general trainings not specifically related to ABA, like a training on restrictive procedures, may have certain sections that are related to ABA. In order for an IBHS provider to count the ABA-related hours of these trainings toward staff training requirements, they should retain documentation from the provider that provides the training which identifies the specific number of hours within the training that is related to ABA.The process to submit trainings for Department approval and lists of trainings that do not require Department review are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, training records, and documentation that shows the date of first independent service provision for any Assistant BC-ABA without a BCBA, BCaBA or BCAT to determine compliance with this section of the regulation. Primary Benefit: To ensure that staff are trained in techniques and subject matters that are important to the independent provision of Assistant BC-ABA services prior to provision of services independently, and to ensure that staff receive annual trainings relevant to the populations served and to ensure staff are qualified.

Regulation: § 5240.83. Training requirements for staff who provide ABA services.(d)  An individual who provides BHT-ABA services shall complete the following:   (1)  Training in accordance with § 5240.73(c), (d) and (f) (relating to training requirements for staff who provide individual services).   (2)  At least 20 hours of training annually related to ABA that is approved by the Department or provided by a continuing education provider approved by the Behavior Analyst Certification Board that is related to the individual’s specific job functions and is in accordance with the individual training plan required under § 5240.13.Discussion: Both §§ 5240.73(c) and 5240.73(d) have training requirements that are dependent on the date of initial provision of BHT services. § 5240.73(c) requires 30 hours of training to be completed prior to the independent provision of IBHS services. § 5240.73(d) requires 24 hours of training to be completed within first 6 months of BHT service provision. IBHS agencies should document the date of initial service provision and the date of first independent provision of service to verify compliance with these sections.For trainings to fulfill the annual training requirement found under § 5240.83(d)(2), they must be related to ABA. Some general trainings not specifically related to ABA, like a training on restrictive procedures, may have certain sections that are related to ABA. In order for an IBHS provider to count the ABA-related hours of these trainings toward staff training requirements, they should retain documentation from the provider that provides the training which identifies the specific number of hours within the training that is related to ABA.OMHSAS has interpreted that both first aid and cardiopulmonary resuscitation (CPR) are inherent within “first aid, universal precautions and safety” under § 5240.73(c)(7) of the IBHS regulations. Certification demonstrates that the individual has learned acceptable techniques.The process to submit trainings for Department approval and lists of trainings that do not require Department review are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, training records, and documentation that shows the date of first independent service provision for any BHT-ABA who has not previously provided BHT services to determine compliance with this section of the regulation. Primary Benefit: To ensure that staff are trained in techniques and subject matters that are important to the independent provision of BHT-ABA services prior to provision of services independently, and to ensure that staff receives annual trainings relevant to the populations served and to ensure staff are qualified.

Regulation: § 5240.83. Training requirements for staff who provide ABA services.(e)  An individual who is certified may count hours of training required to maintain certification towards the training requirement in subsections (b)—(d).Discussion: OMHSAS suggests that IBHS agencies that accept certification in lieu of required training topics have a policy and procedure that outlines the approval of the certification and the process to determine the relevant training topics that the certification covered. This policy and procedure should be reviewed by the OMHSAS Licensing Representative. Inspection Procedures: OMHSAS Licensing Representatives will review staff records, training records, certification, and policies and procedures to determine compliance with this section of the regulation. Primary Benefit: To allow newly hired staff who are certified to apply the knowledge which was required for certification to count towards initial training requirements.

Regulation: § 5240.83. Training requirements for staff who provide ABA services.(f)  An individual who is licensed in this Commonwealth may count hours of training required to maintain licensure towards the training requirements in subsections (b)—(d).Discussion: OMHSAS suggests that IBHS agencies that accept licenses in lieu of required training topics have a policy and procedure that outlines the approval of the license and the process to determine the relevant training topics that the license covered. This policy and procedure should be reviewed by the OMHSAS Licensing Representative Inspection Procedures: OMHSAS Licensing Representatives will review staff records, training records, licenses, and policies and procedures to determine compliance with this section of the regulation. Primary Benefit: To allow newly hired staff who are licensed to apply the knowledge which was required for licensure to count towards initial training requirements.

Regulation: § 5240.84. ABA services initiation requirements.(a)  An IBHS provider shall provide ABA services to a child, youth or young adult in accordance with a written order under § 1155.33(a)(1) (relating to payment conditions for ABA services).Discussion: Although Chapter 1155 outlines medical assistance payment conditions for IBHS, OMHSAS interprets regulation to mean that all IBHS agencies that provide ABA must have a written order that meets the requirements of § 1155.33(a)(1) to initiate IBHS ABA services. The IBHS provider must provide services in accordance with the written order. If an assessment of the child, youth or young adult’s needs determines more service hours are required than are included in the written order, the original written order must be amended or a new written order must be created. If an assessment determines that less hours than the number included in the written order is needed, no change to the written order is necessary.  § 1155.33(a)(1) requires written order for ABA services based on a face-to-face interaction with the child, youth or young adult that meets the following:      (i)   Written within 12 months prior to the initiation of ABA services.     (ii)   Written by a licensed physician, licensed psychologist, certified registered nurse practitioner or other licensed professional whose scope of practice includes the diagnosis and treatment of behavioral health disorders and the prescribing of behavioral health services, including IBHS.     (iii)   Includes a behavioral health disorder diagnosis listed in the most recent edition of the DSM or ICD.     (iv)   Orders ABA services for the child, youth or young adult and includes the following:       (A)   The clinical information to support the medical necessity of each ABA service ordered.       (B)   The maximum number of hours of each ABA service per month.       (C)   The settings where ABA services may be provided.       (D)   The measurable improvements in targeted behaviors or skill deficits that indicate when services may be reduced, changed or terminated. Bulletin OMHSAS-22-02 Revised Guidelines for the Delivery of Behavioral Health Services Through Telehealth provided updated guidance on behavioral health services provided through telehealth. It has been determined by OMHSAS that a written order may be conducted through telehealth, which meets the requirements of a face-to-face interaction outlined in this section of the regulation. Audio-only telehealth would not meet this requirement.   § 1155.33(a)(1)(iv)(B)(C) states a written order must include the maximum hours of each service per month and the setting where services may be provided. This requirement is interpreted by OMHSAS to mean that the written order minimally must identify the settings where services are to be provided (home, school, community, center) and the maximum number of hours per month for each service (Individual, ABA, Group, EBT). Accordingly, the intent of the written order is to provide the settings where services may be provided. Therefor an evaluator may say, for example, “30 hours in the home, school and community”, or “20 hours in the school and 10 hours in the home and community”. The assessment will capture the specific number of hours needed in each setting and should not be in conflict with the written order. Inspection Procedures: OMHSAS Licensing Representatives will review the written order and the individual records to ensure services are provided in accordance with the written order to determine compliance with this section of the regulation. Primary Benefit: To ensure services are provided in accordance with the written order as this provides documentation that the services are medically necessary and provides the framework of the therapeutic services the child requires.

Regulation: § 5240.84. ABA services initiation requirements.(b)  Prior to the initiation of ABA services, the IBHS provider shall obtain written consent to receive the ABA services identified in the written order from the youth, young adult or parent or legal guardian of a child or youth.Discussion: OMHSAS suggests that the consent to receive services either directly includes the recommendation(s) found in the written order or refers the family to the written order, so that their consent to those specified services is documented. For the purpose of required timing, OMHSAS interprets the initiation of services as the first day an individual service is provided. This includes the first day an assessment is conducted. Inspection Procedures: OMHSAS Licensing Representatives will review the consent form and individual record documents to identify the date of the initiation of services to determine compliance with this section of the regulation. Primary Benefit: To ensure that the youth, young adult or parent or legal guardian are consenting to the services outlined in the written order prior to the initiation of these services.

Regulation: § 5240.85. Assessment.(a)  Within 30 days of the initiation of ABA services and prior to completing the ITP, a face-to-face assessment shall be completed for the child, youth or young adult by an individual qualified to provide behavior analytic services or behavior consultation—ABA services.Discussion: As required by section § 5240.85(c)(6) of the IBHS regulations, the child should be assessed across the home, school and other community settings. OMHSAS interprets the initiation of services to mean the first day an ABA service is provided. This includes the first day an assessment is conducted. The timeframes used in the IBHS regulations are for calendar days.An IBHS provider who admits a child, youth, or young adult transferred from another IBHS provider may accept and work off of an assessment completed by the other IBHS provider, as long as it is within 12 months of the date the assessment was completed. Additionally, there should be no occurrence that requires an assessment update as outlined in § 5240.85(e), otherwise a new assessment must be completed. When an IBHS provider is accepting an assessment completed by a different provider, the assessment should be reviewed to ensure it contains all the required elements of an assessment. If the assessment is deficient in any of the required elements, the provider may conduct a new assessment or create an addendum to the assessment to include the missing information. The addendum containing the missing elements of the assessment should be included in the individual record along with the transferred assessment and should also be signed and dated by the staff member who conducted assessment of the missing elements within 30 days of the initiation of services at the IBHS provider. The assessment should be updated based off of the date that the transferred assessment was completed (the date that the assessment was signed by the staff member of the different IBHS provider). Even if an addendum is added to the assessment, it should be updated based off of the original assessment date.A best practice evaluation does not need to be conducted, but it can be conducted if clinically indicated. A best practice evaluation should meet regulatory requirements for a written order for the services ordered (Individual, ABA or Group services) if used as a written order. An assessment is required regardless of whether a best practice evaluation was completed. Unlike a best practice evaluation, the assessment should take place across all environments (home, school, community settings).If a psychological evaluation includes all components required to be included in the assessment, an assessment is still required unless the psychological evaluation was conducted across the home, school and community setting. The level of detail of the assessment may vary based on the information that was included in the psychological evaluation.Individuals who complete functional behavior assessments (FBA) should have completed a training provided by the Bureau of Supports for Autism and Special Populations, formerly Bureau of Autism Services, or have completed the BCBA credential providers offered by a university.If an individual receives multiple IBHS services (Individual, ABA, Group, EBT) from the same IBHS provider, a separate assessment should be completed for each service. Accordingly, the individual record must document the start date of each service if they are not started on the same date. Inspection Procedures: OMHSAS Licensing Representatives will review individual records including initial assessments to determine compliance with this section of the regulation. When FBAs are conducted, OMHSAS Licensing Representatives will review the staff file to verify they have a Bureau of Supports for Autism and Special Populations’ FBA training certificate or their BCBA credential documented.Primary Benefit: To ensure assessments are completed in a timely fashion as outlined in the regulation.

Regulation: § 5240.85. Assessment.(b)  The assessment shall be completed in collaboration with the child, youth, young adult or parent, legal guardian or caregiver of the child or youth, as appropriate.Discussion: OMHSAS interprets this section to mean that a provider should include documentation that shows collaboration occurred which could include an account in the progress note or a statement within the assessment that shows all parties involved in the assessment.  Inspection Procedures: OMHSAS Licensing Representatives will review the initial and ongoing assessment and other documentation that supports the collaboration to determine compliance with this section of the regulation. Primary Benefit: To ensure collaboration has occurred between the assessor and the child/caregiver and has been included in the assessment of needs.

Regulation: § 5240.85. Assessment.(c)  The assessment shall be individualized and include the following:   (1)  The strengths and needs across developmental and behavioral domains of the child, youth or young adult.   (2)  The strengths and needs of the family system in relation to the child, youth or young adult.   (3)  Existing and needed natural and formal supports.   (4)  Clinical information that includes the following:     (i)       Survey data gathered from a parent, legal guardian or caregiver.     (ii)      Treatment history.     (iii)     Medical history.     (iv)     Developmental history.     (v)      Family structure and history.     (vi)     Educational history.     (vii)    Social history.     (viii)   Trauma history.     (ix)     Adaptive skills assessment.     (x)      Other relevant clinical information.   (5)  Completion of standardized behavioral assessment tools as needed.   (6)  Compilation of observational data to identify developmental, cognitive, communicative, behavioral and adaptive functioning across the home, school and other community settings.   (7)  Identification and analysis of skill deficits, targeted behaviors or both, in measurable terms to address needs.   (8)  The cultural, language or communication needs and preferences of the child, youth or young adult and the parent, legal guardian or caregiver.Discussion: Agencies may use the standardized assessment tools (i.e. Vineland, VB-MAPP, ABLLS, ADOS) but if these tools do not cover all of the required elements of this section, OMHSAS suggests that the additional sections be assessed and included as an addendum or an attachment in the individual’s record. Similarly, assessments required by managed care organizations or private insurance providers may be used. However, if required elements are not contained in the assessment, the missing information must be included as an addendum or an attachment to the assessment.The requirements outlined in this section do not preclude IBHS providers to assess areas not covered in this section. Inspection Procedures: OMHSAS Licensing Representatives will review individual files and any documents that are included in the initial or ongoing assessments. Primary Benefit: To ensure a comprehensive assessment has been completed as outlined in the regulation, and to provide consistency in the information shared to enhance quality of services.

Regulation: § 5240.85. Assessment.(d)  The assessment shall include a summary of the treatment recommendations received from health care providers, school or other service providers involved with the child, youth or young adult.Discussion: OMHSAS considers this information a vital piece of an assessment because behaviors may be different across settings. In order to verify this requirement has been met, OMHSAS interprets this section to require the assessment to list the providers who submitted treatment recommendations.  Inspection Procedures: OMHSAS Licensing Representatives will review individual files and any documents that are included in the initial or ongoing assessments. Primary Benefit: Ensures that assessments are informed by a variety of health care, school and service providers who may provide information that may have been missed if not consulted.

Regulation: § 5240.85. Assessment.(e)  The assessment shall be reviewed and updated at least every 12 months or if one of the following occurs:   (1)  A parent, legal guardian or caregiver of the child or youth requests an update.   (2)  The youth or young adult requests an update.   (3)  The child, youth or young adult experiences a change in living situation that results in a change of the child’s, youth’s or young adult’s primary caregivers.   (4)  The child, youth or young adult has made sufficient progress to require an updated assessment.   (5)  The child, youth or young adult has not made significant progress towards the goals identified in the ITP within 90 days from the initiation of the services.   (6)  The child, youth or young adult experiences a crisis event.   (7)  A staff person, primary care physician, other treating clinician, case manager or other professional involved the child’s, youth’s or young adult’s services provides a reason an update is needed.Discussion: OMHSAS interprets the required timeframe of 12 months to mean 365 days.Managed Care Organizations and/or private insurance organizations may have additional requirements beyond the minimum standards found in this section. For example, assessment updates may be required when there is a change in school setting. OMHSAS encourages IBHS providers who provide services to individuals with Medical Assistance to work closely with these organizations to be informed of any such requirements. Inspection Procedures: OMHSAS Licensing Representatives will review individual files and any documents that are included in the updated assessments to determine compliance with this section of the regulation. Primary Benefit: Provides consistency in when the assessment is updated and ensures the individual’s assessed needs are driving treatment.

Regulation: § 5240.85. Assessment.(f)  The assessment and all updates shall be signed and dated by the staff person who completed the assessment.Discussion: The initial and updated assessments must be signed by the individual qualified to provide behavior analytic services or behavior consultation-ABA who completed the assessment. OMHSAS does not consider the assessment completed until it has been signed by the staff person who completed the assessment. Therefore, it must be signed within 30 days of the initiation of service for the initial assessment and must be updated within 365 days of the signature date on the previous assessment.If using electronic records, a process for electronic signatures needs to be in place. Electronic signatures and electronic pad signatures are both acceptable, and the use of a PIN is not prohibited. Inspection Procedures: OMHSAS Licensing Representatives will review assessment documents and all updates for the signature and date of the qualified person who completed the assessment. Primary Benefit: To ensure that qualified staff are signing and dating assessment and all updates.

Regulation: § 5240.86. Individual treatment plan.(a)  A written ITP shall be completed by an individual qualified to provide behavior analytic services or behavior consultation—ABA services within 45 days after the initiation of ABA services and be based on the assessment completed in accordance with § 5240.85 (relating to assessment).Discussion: OMHSAS interprets the completion of an ITP to include the signatures of all required participants, which must be signed off within the 45 day timeframe. The initiation of services is the first day an individual service is provided. This includes the first day an assessment is conducted. The timeframes used in the IBHS regulations are for calendar days.An IBHS provider who admits a child, youth, or young adult transferred from another IBHS provider may accept and provide services utilizing an ITP completed by the other IBHS provider as long as it is within 6 months of the date the ITP was completed. The IBHS provider should review the ITP to ensure it contains all the required elements of an ITP and is signed by all required participants. If the ITP is deficient in any of the required elements, the provider should develop a new ITP. When ITPs developed by a different IBHS provider are used, the ITP should be updated based off of the date the ITP or its most recent update were completed by the previous provider to provide services (the date that all required participants have signed the ITP).  Inspection Procedures: OMHSAS Licensing Representatives will review individual charts for ITPs and the dates they were completed and signed. Primary Benefit: To ensure that there is a treatment plan completed early in services, which guides treatment and is based on the assessment.

Regulation: § 5240.86. Individual treatment plan.(b)  The ITP must include the recommendations from the licensed professional who completed the written order for ABA services in accordance with § 1155.33(a)(1) (relating to payment conditions for ABA services).Discussion: 55 Pa Code § 1155.33(a)(1)(iv) presents the information that must appear in a written order. The following information from the written order must be included in the ITP: the maximum number of hours of each service per month, the settings where services may be provided, and the measurable improvements in the identified therapeutic needs that indicate when services may be reduced, changed or terminated. The “maximum number of hours of each service per month” is in reference to each service type provided: BA, BC-ABA, and/or BHT-ABA services. This information should be presented on the ITP and not included as an attachment to the ITP.Although 55 Pa Code Chapter 1155 is a regulation that outlines requirements for MA payment, OMHSAS interprets regulation to mean that providers who do not accept MA should also include the recommendation information as outlined above from the written order in the ITP. Inspection Procedures: OMHSAS Licensing Representatives will review individual charts for ITPs and compare that to the original written order to ensure that the information is captured. Primary Benefit: To ensure that the treatment recommendations from the written order appear on the ITP. This will help to ensure these recommendations are easily monitored and followed during the ITP review and completion process, or if recommendations were adjusted following an assessment, will serve as a historical account of what was initially recommended.

Regulation: § 5240.86. Individual treatment plan.(c)  The ITP must be strength-based with individualized goals and objectives to address the identified skill deficits, targeted behaviors or both for the child, youth or young adult to function at home, school or in the community.Discussion: OMHSAS suggests that strength-based treatment plans focus on the individual’s internal strengths and resourcefulness and not their deficiencies and failures. The ITP should be person-centered and individualized, with goals that address all living environments regardless of the location in which the services are provided. Staff should also look to ensure that goals include functional skills to increase, not just maladaptive behaviors to decrease.   Inspection Procedures: OMHSAS Licensing Representatives will review individual charts and ITPs to determine the ITP is strength-based with individualized goals for the individual to function at home, school or in the community. Primary Benefit: To ensure that treatment is based on the child, youth, or young adult’s strengths and is specifically tailored to their needs.

Regulation: § 5240.86. Individual treatment plan.(d)  The ITP must include the following:   (1)  Service type and number of hours of each service.   (2)  Specific measurable long, intermediate and short-term goals and objectives to address socially significant behaviors, skill deficits or both.   (3)  Delineation of the frequency of baseline behaviors, the treatment planned to address behaviors, skill deficits or both, and the frequency at which the child’s, youth’s or young adult’s progress in achieving each goal is measured.   (4)  Time frames to complete each goal.   (5)  Whether and how parent, legal guardian or caregiver training, support and participation is needed to achieve the identified goals and objectives.   (6)  ABA interventions that are tailored to achieving the child’s, youth’s or young adult’s goals and objectives.   (7)  Settings where services may be provided.   (8)  Number of hours of service at each setting.   (9)  Safety plan to prevent a crisis, a crisis intervention plan and a transition plan.Discussion: The “number of hours” in subsection (1) and (8) can be written monthly or weekly.  The categories for the “setting” outlined in subsections (7) and (8) include: home, school, community and community like settings, including center based. When reviewing number of hours by setting, licensing representatives may see home and community hours combined.  (Ex) 8 hours of BHT-ABA services delivered in the home/community.  That is an acceptable practice.  However, if a child, youth of young adult is receiving services in a consistent community setting, those hours in that setting should be specified.   (Ex)  20 hours of BHT-ABA services delivered in the community while youth is participating in summer program. OMHSAS interprets this regulation to mean that the required elements of a safety plan outlined in subsection (9) are three separate plans:Safety Plan – A Safety Plan is a tool that can be used to prevent a crisis and keep a child, youth or young adult safe.  It includes resources and contact information that can be used when a child, youth or young adult is in a crises.  Crisis Plan – A Crisis Plan is a tool that can be used during a crisis. It provides detailed and individualized information for what to do during a crisis.  Transition Plan – A Transition Plan is the plan for the child’s, youth’s or young adult’s transition from the crisis event to a return of regular IBHS service provision. Inspection Procedures: OMHSAS Licensing Representatives will review individual records for ITPs to verify the presence of each items listed to determine compliance with this section of the regulation. Primary Benefit: To ensure ITPs are detailed and outline a specific service plan for each child, youth, or young adult.

Regulation: § 5240.86. Individual treatment plan.(e)  The ITP shall be developed in collaboration with the child, youth, young adult or parent, legal guardian or caregiver of the child or youth, as appropriate.Discussion: OMHSAS suggests that IBHS agencies keep documented evidence of collaboration in the development of the ITP within the individual records. This may include, but is not limited to, ITP signatures, contact notes, and progress notes connected to the creation and update of the ITP. Inspection Procedures: OMHSAS Licensing Representatives will review the ITP, contact notes, progress notes and other documents in the individual record to determine compliance with this section of the regulation. Primary Benefit: To ensure individuals receiving services, as well as their caregivers, are involved in the development of their treatment goals.

Regulation: § 5240.86. Individual treatment plan.(f)  The ITP shall be reviewed and updated at least every 6 months or if one of the following occurs:   (1)  The child, youth or young adult has made sufficient progress to require that the ITP be updated.   (2)  The child, youth or young adult has not made significant progress towards the goals identified in the ITP within 90 days from the initiation of ABA services.   (3)  The youth or young adult requests an update.   (4)  A parent, legal guardian or caregiver of the child or youth requests an update.   (5)  The child, youth or young adult experiences a crisis event.   (6)  The ITP is no longer clinically appropriate for the child, youth or young adult.   (7)  A staff person, primary care physician, other treating clinician, case manager or other professional involved in the child’s, youth’s or young adult’s services provides a reason an update is needed.   (8)  The child, youth or young adult experiences a change in living situation that results in a change of the child’s, youth’s or young adult’s primary caregivers.Discussion: OMHSAS suggests the reason for the ITP update should be documented in the ITP or in a progress note, as this information will illustrate the nature of the ITP update and give clarity to the updated information.Managed Care Organizations and private insurance organizations may have additional requirements beyond the minimum standards found in this section, for example, ITP updates may be required when there is a change in a school setting. OMHSAS encourages IBHS providers to work closely with these organizations to be informed of any such requirements.OMHSAS interprets subsection (6) to require treatment plan updates to occur when a significant increase or decrease in treatment delivery or significant changes to the individual’s schedule occurs which would cause the current treatment goals to no longer be clinically appropriate. A change or addition of a new IBHS service, e.g. if an individual is receiving Individual IBHS services and switches to a Group IBHS service, should result in a new treatment plan for the service being added. Inspection Procedures: OMHSAS Licensing Representatives will review updated ITPs and accompanying clinical documentation to show the reasons for changes to the ITP to determine compliance with this section of the regulation. Primary Benefit: To ensure ITPs that are guiding treatment are reviewed and updated regularly; or when an update is requested, when a plan-altering life event occurs, or when progress or lack of progress necessitates an ITP update.

Regulation: § 5240.86. Individual treatment plan.(g)  An ITP update must include the elements in subsection (d) and the following:   (1)  A description of progress or lack of progress toward previously identified goals and objectives.   (2)  A description of any new goals, objectives and interventions.   (3)  A description of any changes made to previously identified goals, objectives or interventions.   (4)  A description of any new interventions to be used to reach previously identified goals and objectives.Discussion: In order to objectively identify the progress or lack of progress towards goals and objectives, OMHSAS suggests that the ITP contains measurable goals and objectives. Inspection Procedures: OMHSAS Licensing Representatives will review individual records to include ITP updates to determine compliance with this section of the regulation. Primary Benefit: To ensure consistency in required elements of the ITP update, the ongoing progress measurement, and changes to the plan occur as needed.

Regulation:   § 5240.86. Individual treatment plan.(h)  The ITP and all updates shall be reviewed, signed and dated by the youth, young adult or parent or legal guardian of a child or youth, and the staff person who completed the ITP. Discussion: OMHSAS interprets regulation to mean that the initial and updated ITPs should be signed by the youth, young adult or parent or legal guardian of the child or youth, and the staff person who completed the ITP. Per § 5240.87(a), only staff members qualified to provide behavior analytic services and behavior consultation—ABA services may develop and revise ITPs. OMHSAS suggests that title/position should be displayed next to the signature as signatures are not always easy to identify. If using electronic records, a process for electronic signatures needs to be in place. Electronic signatures and electronic pad signatures are both acceptable, and the use of a PIN is not prohibited. When ITP or updates are created through telehealth, the staff should sign, but the youth, young adult or parent or legal guardian may give verbal consent via telehealth. OMHSAS considers an ITP to be effective on the date that all required signatures have been documented on the ITP. Accordingly, all signatures outlined in this section and in § 5240.86(i) must be documented in the ITP on or before the due date for the ITP or ITP update completion. For example, an IBHS provider should have the youth, young adult or parent or legal guardian of the child or youth, the staff member who completed the ITP, and the individual who meets the qualifications of a clinical director (as outlined in § 5240.86(i)) complete the initial ITP and all sign within 30 days from the initial service date. The updated ITP must be signed by those required in this section and in § 5240.86(i) within 6 months (180 days) of the final required signature included in the previous ITP. Inspection Procedures: OMHSAS Licensing Representatives will review initial and updated ITPs for signatures and dates, and/or documentation of participation in the ITP process to determine compliance with this section of the regulation. Primary Benefit: To ensure youth, young adult or parent or legal guardian of the child or youth, and the qualified staff members have documentation to verify their involvement in the creation of the initial and updated ITPs.

Regulation: § 5240.86. Individual treatment plan.(i)  The ITP and all updates shall be reviewed, signed and dated by an individual who meets the qualifications of a clinical director in §  5240.81 (relating to staff qualifications for ABA services).Discussion: OMHSAS suggests that title/position should be displayed next to the signature as signatures are not always easy to identify. If the signature is of an individual who meets qualification requirements but is not acting in the role of the clinical director, it is recommended to identify the qualification of this staff member as “clinical director qualified”.If the signature is of an individual who meets qualification requirements but is not acting in the role of the clinical director, it is recommended to identify the qualification of this staff member as “clinical director qualified”. OMHSAS interprets this section to require the ITP and updates created by an individual who meets qualifications but is not acting in the role of a clinical director to additionally be signed by another staff member who meets the qualifications of a clinical director. Additionally, OMHSAS suggests that an additional staff who meets the qualification of a clinical director, when possible, signs the ITP and updates when they are created by the staff acting in the role of the clinical director. OMHSAS considers an ITP to be effective on the date that all required signatures have been documented on the ITP. Accordingly, all signatures outlined in this section and in § 5240.86(h) must be documented in the ITP on or before the due date for the ITP or ITP update completion. For example, an IBHS provider should have the youth, young adult or parent or legal guardian of the child or youth, the staff member who completed the ITP (as outlined in § 5240.86(h)), and the individual who meets the qualifications of a clinical director complete the initial ITP and all sign within 45 days from the initial service date. The updated ITP must be signed by those required in this section and in § 5240.86(h) within 6 months (180 days) of the final required signature included in the previous ITP. Inspection Procedures: OMHSAS Licensing Representatives will review ITPs for signatures of staff qualified to be the clinical director and dates to determine compliance with this section of the regulation. Primary Benefit: To ensure a staff member qualified to be a clinical director is reviewing ITPs and participating in the ITP process.

Regulation: § 5240.87. ABA services provision.(a)  Behavior analytic services and behavior consultation—ABA services consist of clinical direction of services to a child, youth or young adult; development and revision of the ITP; oversight of the implementation of the ITP and consultation with a child’s, youth’s or young adult’s treatment team regarding the ITP.Discussion: Because only those who meet qualifications for BA and BC-ABA services may conduct an ABA assessment, OMHSAS interprets the term “clinical direction of services” to include conducting assessments. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, supervision records, and individual records including individual treatment plans, progress notes, other relevant records. OMHSAS Licensing Representatives may interview staff as needed. Primary Benefit: To ensure BAs and BC-ABAs provide ABA services as outlined in the regulation.

Regulation: § 5240.87. ABA services provision.(b)  In addition to the services listed in subsection (a), behavior analytic services include functional analysis.Discussion: None. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, supervision records, staff trainings and certifications, and individual records including, but not limited to, functional assessments. OMHSAS Licensing Representatives may interview staff as needed. Primary Benefit: To allow those who meet the qualifications to provide BA services to additionally provide functional analysis.

Regulation: § 5240.87. ABA services provision.(c)  Assistant behavior consultation—ABA services consist of assisting an individual who provides behavior analytic services or behavior consultation—ABA services and providing face-to-face behavioral interventions.Discussion: OMHSAS interprets regulation to mean that an Assistant BC-ABA can provide face-to-face behavioral interventions under the direction of a BA or BC-ABA, and may assist with tasks including, but not limited to, assisting with the assessment, helping to ensure the family understands a new intervention, and data collection. Although the Assistant BC-ABA may assist with certain components of the assessment and treatment plans, they are not able to analyze the data or findings or solely create a treatment plan.   Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, supervision records, and individual records. OMHSAS Licensing Representatives may interview staff as needed. Primary Benefit: To ensure Assistant BC-ABAs provide ABA services as outlined in the regulation.

Regulation: § 5240.87. ABA services provision.(d)  BHT-ABA services consist of implementing the ITP.Discussion: OMHSAS interprets regulation to mean that a BHT-ABA’s implementation of the ITP must be under the direction of the individual who developed the ITP. Services provided by the BHT-ABA may include the collection of data and implementation of interventions as guided by the treatment team lead and outlined in the ITP. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, supervision records, and individual records including individual treatment plans, progress notes, collected data, other relevant records. OMHSAS Licensing Representatives may interview staff as needed. Primary Benefit: To ensure BHT-ABAs provide ABA services as outlined in the ITP.

Regulation: § 5240.87. ABA services provision.(e)  An individual who provides assistant behavior consultation—ABA services and BHT-ABA services may not provide interventions requiring skills, experience, credentials or licensure that the individual does not possess.Discussion: OMHSAS interprets regulation to mean that only BHT-ABAs with the required skills, experience, credentials or licensure may provide specialized interventions that have such requirements. For example, interventions utilizing Acceptance and Commitment Therapy (ACT) should only be individuals how have been trained to do so. It is up to the IBHS provider that provides specialized interventions to understand the requirements that are needed and to document in the staffing records how these requirements are met. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, supervision records, training records, HR files, and individual records including individual treatment plans, progress notes, collected data, other relevant records. OMHSAS Licensing Representatives may interview staff as needed. Primary Benefit: To ensure Assistant BC-ABAs and BHT-ABAs have necessary training, education, skills, experience and credentials to provide interventions as outlined in applicable ITPs.

GROUP SERVICES

Regulation: § 5240.91. Staff requirements and qualifications for group services.(a)  In addition to the staff required under § 5240.11 (relating to staff requirements), an IBHS provider that provides group services shall have a graduate-level professional who meets one of the following qualifications:   (1)  The qualifications to provide behavior consultation services in § 5240.71(a) (relating to staff qualifications for individual services).   (2)  The qualifications to provide mobile therapy services in § 5240.71(c).   (3)  The qualifications to provide behavior analytic services in § 5240.81(d)(relating to staff qualifications for ABA services).   (4)  The qualifications to provide behavior consultation—ABA services in § 5240.81(e).Discussion: § 5240.11, which is cited in the above regulation, requires a sufficient number of qualified staff to be employed in order to meet the clinical and administrative responsibilities of the provider. On top of the requirements in § 5240.11, group services require at least one graduate level professional onsite during hours in which services are provided.Additionally, the IBHS regulations do not set a required staff-to-individual ratio. IBHS agencies who provide Group services should follow their approved service description, which includes the maximum number of individuals served at one time through Group, per § 5240.5(a)(11). IBHS agencies providing Group services should keep attendance records to verify adherence to this element of their service description. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, HR files, and Group service attendance records to determine compliance with this section. OMHSAS Licensing Representatives will review credentials for all new staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: Ensures that Group services have the basic staffing structure as outlined in § 5240.11.

Regulation: § 5240.91. Staff requirements and qualifications for group services.(b)  Group services may also be provided by an individual who meets one of the following:   (1)  The qualifications to provide BHT services in § 5240.71(d).   (2)  The qualifications to provide BHT-ABA services in § 5240.81(g).Discussion: None. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, and HR files to determine compliance with this section. OMHSAS Licensing Representatives will review credentials for all new staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: Ensures that BHT and BHT-ABA providers in Group services meet their respective qualification requirements.

Regulation: § 5240.91. Staff requirements and qualifications for group services.(c)  An IBHS provider that provides group services that include specialized therapies such as music, dance and movement, play or occupational therapies shall use clinical staff to provide the specialized therapies who meet one of the following:   (1)  Are Nationally certified or licensed in this Commonwealth in the specific therapy.   (2)  Are graduate-level professionals with a minimum of 12 graduate-level credit hours in the specialized therapy and a minimum of 1 year of supervised experience in the use of the specialized therapy technique.Discussion: When IBHS agencies providing specialized services hire staff to provide these services, the provider should verify and store in the staff’s record the certification or license, the graduate-level transcript, the resume, and documentation that verifies the supervision that occurred. OMHSAS suggests that supervision documentation includes the name and qualification of the supervisor who provided supervision during this experience.  Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, and HR files to determine compliance with this section. OMHSAS Licensing Representatives will review credentials for all new staff during the initial licensing visit and annually. A sample of at least 10% of existing staff will be conducted annually. Primary Benefit: Ensures that BHT and BHT-ABA providers in Group services meet their respective qualification requirements.

Regulation: § 5240.92. Supervision of staff who provide group services.(a)  An individual who meets the qualifications of a clinical director shall provide the following supervision to a graduate-level professional:   (1)  One hour of individual face-to-face supervision per month that includes oversight of the following:     (i)     The specific interventions being implemented.     (ii)    The child’s, youth’s or young adult’s progress towards the goals of the ITP.     (iii)   Consideration of adjustments needed to the ITP.     (iv)   The staff person’s skills in implementing the interventions in the ITP.   (2)  If the graduate-level professional supervises an individual who is qualified to provide BHT services or BHT-ABA services, the graduate-level professional shall receive an additional hour of face-to-face supervision per month that includes a discussion of the BHT or BHT-ABA services being provided.Discussion: IBHS agencies providing Group services not utilizing ABA may use any individual who meets the qualifications of a clinical director under § 5240.12(b) to provide supervision to graduate level professionals. IBHS agencies providing Group services utilizing ABA may use any individual who meets the qualifications of a clinical director for ABA services under § 5240.81(c) to provide supervision to graduate level professionals. It is up to the provider to decide how to utilize individuals who meet these qualifications to meet the supervision requirements. However, the clinical director is ultimately responsible for ensuring that staff who provide graduate level professional services are supervised in accordance with the IBHS regulations. OMHSAS interprets this section to require arrangements for peer supervision by an individual who meets the qualification of a clinical director for the service type provided (individual or ABA) when an IBHS agency’s clinical director provides BC, MT, BA or BC-ABA services in the Group setting. If a clinical director for Group services does not typically provide services directly with the individuals in the program but will provide these services when a staff member who normally provides these services is unavailable, OMHSAS suggests the IBHS provider should develop a policy and procedure to outline the circumstances when the clinical director will provide services and how the clinical director will seek peer supervision to cover the period when the clinical director is providing services. OMHSAS suggests at a minimum this should include the name of the individual who will conduct the peer supervision, confirmation that the individual who provides peer supervision meets the qualification of a clinical director for the service provided (Individual, ABA), and the method, frequency, and duration of the supervision. The policy and procedure will be reviewed by OMHSAS as part of licensing. OMHSAS interprets that the additional hour of supervision required under § 5240.92(a)(2), is not necessary for a clinical director who is supervising staff, nor is there a requirement that the peer providing supervision of the clinical director sign off on any documents in the individual records.  The hour(s) of supervision required may be a combination of shorter-length supervision sessions that add up to the required timeframe. OMHAS interprets that the additional hour of supervision required when a graduate level professional supervises a BHT or BHT-ABA may be provided through group supervision as long as the graduate level professional receives one hour of individual face-to-face supervision.When a staff member provides multiple types of IBHS services, they should receive supervision related to each IBHS service they deliver. However, there is no need to supervise the service provision separately because supervision related to multiple types of IBHS can occur concurrently. For example, staff who provide both MT and graduate level professional Group services can receive a total of 1 hour of supervision per month. This supervision would then cover both services rather than receiving separate 1 hour per month supervision addressing MT services and another 1 hour per month supervision addressing graduate level professional Group services. If there are different supervision requirements, staff providing multiple types of IBHS should receive the highest amount of supervision required for the IBHS the staff person provides. Supervision of staff providing multiple types of IBHS must be conducted by a qualified supervisor.  A supervisor is qualified if they are permitted to conduct the supervision of each of the services provided by the staff member under the IBHS regulation. The IBHS regulations require direct observation to occur while staff are providing services directly to the child, youth or young adult. As a result, observing a staff person who provides graduate level professional services conduct a treatment team meeting would not count as direct observation. Observing staff conduct a treatment team meeting could be considered supervision. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures for clinical director supervision when clinical director provides IBHS services, to determine compliance with this section of the regulation. Primary Benefit: To ensure regular supervision and direct observation for all graduate level professionals to maintain quality of care.

Regulation: § 5240.92. Supervision of staff who provide group services.(b)  A graduate-level professional shall provide the following supervision to individuals who are qualified to provide BHT services or BHT-ABA services:   (1)  One hour of supervision each week if the individual works at least 37.5 hours per week or 1 hour of supervision two times a month if the individual works less than 37.5 hours a week. The individual must receive 1 hour of individual face-to-face supervision each month.   (2)  The supervision must include oversight of the following:     (i)     The interventions being implemented.     (ii)    The child’s, youth’s or young adult’s progress towards the goals of the ITP.     (iii)   Consideration of adjustments needed to the ITP.     (iv)   The staff person’s skills in implementing the interventions in the ITP.Discussion: IBHS agencies providing Group services not utilizing ABA may use any individual who meets the minimum qualifications of a graduate-level professional under §§ 5240.71(b) or 5240.71(c) to provide supervision to BHTs. IBHS agencies providing Group services utilizing ABA may only use individuals who meet the qualifications of a graduate-level professional for ABA services under § 5240.81(d), § 5240.81(e), or § 5240.81(f), to provide supervision to BHT-ABAs. It is up to the provider to decide how to utilize individuals who meet these qualifications to meet the supervision requirements. However, the clinical director is ultimately responsible for ensuring that staff who provide IBHS are supervised in accordance with the IBHS regulations.The 37.5 hours per week requirement used to determine the frequency of supervision includes all time the individual works, including hours the individual is not providing face-to-face BHT/BHT-ABA services.The hour(s) of supervision required may be a combination of shorter-length supervision sessions that add up to the required timeframe. When a staff member provides multiple types of IBHS services, they should receive supervision related to each IBHS service they deliver. However, there is no need to supervise the service provision separately because supervision related to multiple types of IBHS can occur concurrently. For example, staff who provide both Group BHT and BHT-ABA can receive a total of 1 hour of supervision per month which covers both services rather than receiving separate 1 hour per month supervision addressing Group BHT services and another 1 hour per month supervision addressing BHT-ABA services. If there are different supervision requirements, staff providing multiple types of IBHS should receive the highest amount of supervision required for the IBHS the staff person provides. Supervision of staff providing multiple types of IBHS should be conducted by a qualified supervisor.  A supervisor is qualified if they are permitted to conduct the supervision of each of the services provided by the staff member under the IBHS regulation. The Department expects that there will be a need for supervision to occur outside of the presence of the child, youth or young adult. For example, a supervisor may need to discuss feedback with an individual providing BHT services or BHT-ABA services which may not be appropriate to discuss in front of the child, youth, young adult or caregiver. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures and any other relevant documentation to determine compliance with this section of the regulation. Primary Benefit: To ensure regular supervision and direct observation for BHT-ABA staff to maintain quality of care.

Regulation: § 5240.92. Supervision of staff who provide group services. (c)  Group supervision may be provided to no more than 12 staff who provide group services, but only nine of the staff can be qualified to provide BHT services or BHT-ABA services. Discussion: A qualified supervisor is permitted to supervise a total of 12 staff members who provide Group services in a group supervision setting, of which up to 9 may be staff who provide BHT or BHT-ABA Group services. For example, a supervisor may provide group supervision to 9 BHT-ABAs and 3 BC-ABAs, but a group containing 10 BHTs and 2 BCs would not be allowable under the regulation.  IBHS agencies who provide both Group services not utilizing ABA and Group services utilizing ABA should ensure that graduate-level professionals providing Group ABA and BHT-ABAs are included only in group supervision that focuses on the provision of ABA.    A qualified supervisor cannot supervise multiple groups of 12 staff at different times. As outlined in § 5240.92(g), documentation of group supervision should be included in the supervised staff member’s personnel file. Therefore, if one group supervision note is created it should be copied and included in all supervised staff members personnel files. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures, personnel files, and any other relevant documentation to determine compliance with this section of the regulation. Primary Benefit: To allow group supervision for staff that ensures ratio between supervisor and supervisees allow individualized interaction.

Regulation: § 5240.92. Supervision of staff who provide group services. (d)  An individual may supervise a maximum of 12 full-time equivalent staff that provide group services, but only nine of the full-time equivalent staff can be qualified to provide BHT services or BHT-ABA services. Discussion: OMHSAS interprets full-time equivalency (FTE) to include time spent in both direct service provision and non-billable activities related to behavioral health services. When determining if an individual who provides IBHS services works a full-time equivalent, the IBHS provider should include all hours the individual is considered to be working for the IBHS provider, not the specific level of service. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, supervision tracking documents, policies and procedures, personnel files, and any other relevant documentation to determine compliance with this section of the regulation. Primary Benefit: To allow group supervision for staff that ensures ratio between supervisor and supervisees allow individualized interaction.

Regulation: § 5240.92. Supervision of staff who provide group services. (e)  A supervisor shall be available to consult with staff during the hours that group services are provided, including evenings and weekends.Discussion: OMHSAS interprets this section to require IBHS agencies to have policies and procedures in place to make sure a supervisor is available for consultation with staff during all hours when group services are being provided. OMHSAS interprets the term “available” used in this section to mean the supervisor should be on-site (at the facility) during the hours in which the on-site services are provided. The interpretation of “available” differs in this section of the regulation due to the child, youth, or young adult being on-site and in the care of the IBHS provider. The supervisor should be on-site to respond to any potential crisis or other behavioral concerns.  Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, organizational chart, policies and procedures, staff schedules and other documentation that verifies the availability of the supervisor to determine compliance with this section of the regulation. Primary Benefit: To ensure adequate clinical support is provided to staff providing Group services.

Regulation: § 5240.92. Supervision of staff who provide group services. (f)  Face-to face supervision may be delivered through secure, real-time, two-way audio and video transmission that meets technology and privacy standards required by the Health Insurance Portability and Accountability Act of 1996 (Pub.L. No. 104-191).Discussion: Face-to-face supervision may include the use of HIPAA-compliant audio-video communication products. OMHSAS interprets the absence of audio-only telephone conversation in this section to mean that it is not an acceptable practice used to conduct supervision. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, supervision tracking documents to determine method used for supervision, documentation that verifies any utilized audio-video platform is HIPAA compliant, and the provider’s HIPAA business associate agreement(s) with utilized audio-video platform providers to determine compliance with this section of the regulation. Primary Benefit: To ensure adequate clinical support is provided to staff providing Group services in a format that protects privacy and security of protected health information.

Regulation: § 5240.92. Supervision of staff who provide group services. (g)  A supervisor shall maintain documentation about each supervision session in the supervised staff person’s personnel file that includes the following:   (1)  The date of the supervision session.   (2)  The location and modality of the session, such as in-person or through secure real-time, two-way audio and video transmission.   (3)  The format of the session, such as individual, group or onsite.   (4)  The start and end time of the supervision session.   (5)  A narrative summary of the points discussed during the session.   (6)  The signature and signature date of the supervisor and the staff person receiving the supervision.Discussion: OMHSAS interprets this section of the regulation to mean that a record of each supervision session (individual supervision and, if applicable, group supervision) should be kept and be considered part of personnel records. IBHS agencies may additionally keep a provider-wide record of each supervision session and supervision tracking documentation outside of personnel records.  Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, supervision notes, and personnel records to determine compliance with this section of the regulation. Primary Benefit: To ensure that supervision is documented in a standard way with detailed information.

Regulation: § 5240.93. Training requirements for staff who provide group services.(a)  An IBHS provider that provides group services shall ensure that staff complete initial and annual training requirements. Discussion: OMHSAS interprets this section to require IBHS providers to develop policies to track and monitor the completion of trainings to ensure requirements are met. It is recommended that IBHS agencies should retain physical copies or printouts of training certificates to demonstrate that an individual has completed training.OMHSAS suggests that IBHS agencies should keep a record of training in each staff member’s personnel files instead of a provider-wide record devoted to training because training files should be retained for at least 4 years after staff member is no longer employed with the provider per § 5240.42(b)(2) (relating to provider records). Otherwise, OMHSAS suggests that IBHS agencies develop policies and procedures to assure that training records of staff who no longer are employed are kept for this timeframe. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, policies and procedures, and all initial and annual training documentation, training tracking documents to determine the requirements of this section of the regulation are met. Primary Benefit: To ensure initial and annual training requirements are met.

Regulation: § 5240.93. Training requirements for staff who provide group services.(b)  A graduate-level professional who is qualified to provide behavior consultation services in accordance with § 5240.71(a) (relating to staff qualifications for individual services) shall complete the annual training requirements included in § 5240.73(b), (g) and (h) (relating to training requirements for staff who provide individual services).Discussion: OMHSAS interprets § 5240.83(b) to require IBHS agencies to indicate the timeframe used to determine staff members’ annual training requirements in a training policy and procedure or similar document. These timeframes may include, but are not limited to, calendar year, fiscal year, and annual range from date of hire.The process to submit trainings for Department approval and lists of trainings that do not require Department review and approval are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, training records, and individual training plans to determine the requirements of this section of the regulation are met. Primary Benefit: To ensure that staff receive trainings relevant to the populations served and to ensure staff are qualified.

Regulation: § 5240.93. Training requirements for staff who provide group services.(c)  A graduate-level professional who is qualified to provide mobile therapy services in accordance with § 5240.71(c) shall complete the training required by § 5240.73(b), (g) and (h).Discussion: OMHSAS interprets § 5240.83(b) to require IBHS agencies to indicate the timeframe used to determine staff members’ annual training requirements in a training policy and procedure or similar document. These timeframes may include, but are not limited to, calendar year, fiscal year, and annual range from date of hire.The process to submit trainings for Department approval and lists of trainings that do not require Department review and approval are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, training records, and individual training plans to determine the requirements of this section of the regulation are met. Primary Benefit: To ensure that staff receive trainings relevant to the populations served and to ensure staff are qualified.

Regulation: § 5240.93. Training requirements for staff who provide group services.(d)  A graduate-level professional who is qualified to provide behavior analytic services or behavior consultation—ABA services in accordance with §  5240.81(d) or (e) (relating to staff qualifications for ABA services) shall complete the training required by §  5240.83(b), (e) and (f) (relating to training requirements for staff who provide ABA services).Discussion: OMHSAS interprets § 5240.83(b) to require IBHS agencies to indicate the timeframe used to determine staff members’ annual training requirements in a training policy and procedure or similar document. These timeframes may include, but are not limited to, calendar year, fiscal year, and annual range from date of hire.The process to submit trainings for Department approval and lists of trainings that do not require Department review and approval are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, training records, licenses, certifications, and individual training plans to determine the requirements of this section of the regulation are met. Primary Benefit: To ensure that staff receive annual trainings relevant to the populations served and to ensure staff are qualified.

Regulation: § 5240.93. Training requirements for staff who provide group services.(e)  An individual who meets the qualifications to provide BHT services in accordance with § 5240.71(d) shall complete the training required by § 5240.73(c)—(h).Discussion: OMHSAS suggests that IBHS agencies have a standardized training program developed for newly hired BHTs without prior experience to assure that all required content is met. OMHSAS interprets § 5240.73(c) to require IBHS agencies to document the date of the initial independent service provision for BHT/BHT-ABAs without previous BHT experience in order to verify the 30 hours of training to be completed prior to provision of independent services.OMHSAS interprets § 5240.73(d) to require IBHS agencies to document the date of the initial service provision for BHT/BHT-ABAs without previous BHT experience in order to verify the 24 hours of training to be completed within the first 6 months of BHT service provision were met.A mandated reporter training completed prior to hire may be considered towards the training requirement under § 5240.73(c)(1) as long as the training is valid on the date of hire. The mandated reporter training is valid for a period of 5 years. OMHSAS has interpreted that both first aid and cardiopulmonary resuscitation (CPR) are inherent within “first aid, universal precautions and safety” under § 5240.73(c)(7) of the IBHS regulations. Certification demonstrates that the individual has learned acceptable techniques.An individual who completed a 40-hour RBT Task List training before being hired may count corresponding content areas of that training that align with the requirements toward the 30 hours of training needed prior to working independently required under § 5240.73(c) and the 24 hours of training required during the first six months of employment required under § 5240.73(d).OMHSAS suggests that IBHS agencies that accept completed college coursework, licenses, and certifications for required training topics shall have a policy and procedure that outlines the approval of completed college coursework, licenses, and certifications and the process to determine the relevant training topics that the coursework covered. The process to submit trainings for Department approval and lists of trainings that do not require Department review and approval are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review staff training records (including trainings completed prior to hire date), transcripts, licenses, certifications, and documentation that shows the date the BHT began providing services to determine compliance with this section of the regulation. Primary Benefit: To ensure that staff are trained in techniques and subject matters that are important to the independent provision of BHT services prior to provision of services independently.

Regulation: § 5240.93. Training requirements for staff who provide group services.(f)  An individual who meets the qualifications to provide BHT-ABA services in accordance with § 5240.81(g) shall complete the training required by § 5240.83(d)—(f).Discussion: OMHSAS interprets § 5240.73(d) [referenced in 5240.83(d)(1)] to require IBHS agencies to document the date of the initial service provision for BHT/BHT-ABAs without previous BHT experience in order to verify the 24 hours of training to be completed within the first 6 months of BHT service provision was met.For training to fulfill the annual training requirement found under § 5240.83(d)(2), they should be related to ABA. General training not specifically related to ABA, e.g. a training on restrictive procedures, may have certain sections that are related to ABA. In order for an IBHS provider to count the ABA-related hours of these trainings toward staff training requirements, they should retain documentation from the training provider that identifies the specific number of hours within the training that is related to ABA.OMHSAS suggests that IBHS agencies that count hours of training required to maintain licenses and certifications in lieu of required training topics shall have a policy and procedure that outlines the approval of the certification and the process to determine the relevant training topics that the license or certification covered. The process to submit trainings for Department approval and lists of trainings that do not require Department review and approval are located on the Department’s IBHS website. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, training records, licenses, certifications, and documentation that shows the date of first independent service provision for any BHT-ABA who has not previously provided BHT services to determine compliance with this section of the regulation. Primary Benefit: To ensure that staff are trained in techniques and subject matters that are important to the independent provision of BHT-ABA services prior to provision of services independently, to ensure that staff receive annual trainings relevant to the populations served, and to ensure staff are qualified.

Regulation: § 5240.94. Group services initiation requirements.(a)  An IBHS provider shall provide group services to a child, youth or young adult in accordance with a written order under § 1155.34(a)(1) (relating to payment conditions for group services).Discussion: Written orders for Group services must meet the requirements of § 1155.34(a)(1). This section in turn requires that the written order meets requirements of § 1155.32(a)(1). § 1155.32(a)(1) requires a written order for services based on face-to-face interaction with the child, youth or young adult that meets the following:     (i)   Written within 12 months prior to the initiation of IBHS.     (ii)   Written by a licensed physician, licensed psychologist, certified registered nurse     practitioner or other licensed professionals whose scope of practice includes the  diagnosis and treatment of behavioral health disorders and the prescribing of  behavioral health services, including IBHS.     (iii)   Includes a behavioral health disorder diagnosis listed in the most recent edition of the DSM or ICD.     (iv)   Orders one or more IBHS for the child, youth or young adult and includes the following:       (A)   The clinical information to support the medical necessity of the service ordered.       (B)   The maximum number of hours of each service per month.       (C)   The settings where services may be provided.       (D)   The measurable improvements in the identified therapeutic needs that indicate when services may be reduced, changed or terminated.§ 1155.32(a)(1)(iv)(B)-(C) states a written order must include the maximum hours of each service per month and the setting where services may be provided. This requirement is interpreted by OMHSAS to mean that the written order minimally must identify the settings where services are to be provided (home, school, community, center) and the maximum number of hours per month for each service (Individual, ABA, Group, EBT). Therefore a written order may include, for example, “30 hours in the home, school and community”, or “20 hours in the school and 10 hours in the home and community”. The assessment will capture the specific number of hours needed in each setting and should not be in conflict with the written order.Bulletin OMHSAS-22-02 Revised Guidelines for the Delivery of Behavioral Health Services Through Telehealth provided updated guidance on behavioral health services provided through telehealth. It has been determined by OMHSAS that a written order may be conducted through telehealth, which meets the requirements of a face-to-face interaction outlined in this section of the regulation. OMHSAS does not interpret audio-only telehealth as appropriate to meet this requirement.    Inspection Procedures: OMHSAS Licensing Representatives will review the written order and the individual records to ensure services are provided in accordance with the written order to determine compliance with this section of the regulation. Primary Benefit: To ensure services are provided in accordance with the written order as this provides documentation that the services are medically necessary and provides the framework of the therapeutic services the child requires.

Regulation: § 5240.94. Group services initiation requirements.(b)  Prior to the initiation of group services, the IBHS provider shall obtain written consent to receive the group services identified in the written order from the youth, young adult or parent or legal guardian of a child or youth.Discussion: OMHSAS suggests that the consent to receive services either includes the recommendation(s) found in the written order or refers the family to the written order. This way, their consent to those specified services is documented. For the purpose of required timing, OMHSAS interprets the initiation of services as the first day an individual service is provided. This includes the first day an assessment is conducted. Inspection Procedures: OMHSAS Licensing Representatives will review the consent form and individual record documents including the written order to identify the date of the initiation of services to determine compliance with this section of the regulation. Primary Benefit: To ensure that the youth, young adult or parent or legal guardian are consenting to the services outlined in the written order prior to the initiation of these services.

Regulation: § 5240.95. Assessment.(a)  A face-to-face assessment shall be completed by a graduate-level professional for a child, youth or young adult within 15 days of the initiation of group services in accordance with § 5240.21(b)—(d) and (f) (relating to assessment) and prior to completing the ITP.Discussion: All assessments for Group services, whether the services provided include an ABA services provision, must be completed within 15 days of the initiation of services. Additionally, according to § 5240.97(e), an IBHS provider that provides Group ABA services shall conduct assessments that meet the requirements of § 5240.85. Accordingly, all requirements found in § 5240.85(b)—(d) and (f) must be followed for assessments conducted for Group ABA services.As required by sections §§ 5240.21(c)(7) and 5240.85(c)(6), the child should be assessed across the home, school and other community settings. OMHSAS interprets the initiation of services to mean the first day a Group service is provided. This includes the first day an assessment is conducted. The timeframes used in the IBHS regulations are for calendar days.An IBHS provider who admits a child, youth, or young adult transferred from another IBHS provider may accept and work off of an assessment completed by the other IBHS provider. The assessment must be within 12 months of the date the assessment was completed and there can be no occurrence that requires an assessment update as outlined in § 5240.21(e), otherwise a new assessment must be completed. When an IBHS provider is accepting an assessment completed by a different provider, the assessment should be reviewed to ensure it contains all the required elements of an assessment. If the assessment is deficient in any of the required elements, the provider may conduct a new assessment or create an addendum to the assessment to include the missing information. The addendum containing the missing elements of the assessment should be included in the individual record along with the transferred assessment and should be signed and dated by the staff member who conducted the assessment of the missing elements within 15 days of the initiation of individual group services or 30 days of the initiation of group ABA services at the IBHS provider. The assessment should be updated based on the date that the transferred assessment was completed (the date that the assessment was signed by the staff member of the different IBHS provider). Even if an addendum is added to the assessment it should be updated based on the original assessment date.A best practice evaluation does not need to be conducted but can be conducted if clinically indicated. A best practice evaluation should meet regulatory requirements for a written order for the services ordered (Individual, ABA or Group services) if used as a written order. An assessment is required regardless of if a best practice evaluation was completed. Unlike a best practice evaluation, the assessment should take place across all environments (home, school, community settings).If a psychological evaluation includes all components required to be included in the assessment, an assessment is still required unless the psychological evaluation was conducted across the home, school and community setting. The level of detail of the assessment may vary based on the information that was included in the psychological evaluation.Individuals who complete functional behavior assessments (FBA) should have completed a training provided by the Bureau of Supports for Autism and Special Populations, formerly Bureau of Autism Services, or have completed the BCBA credential providers offered by a university.If an individual receives multiple IBHS services (Individual, ABA, Group, EBT) from the same IBHS provider, a separate assessment should be completed for each service. Accordingly, the individual record should document the start date of each service if they are not started on the same date. Inspection Procedures: OMHSAS Licensing Representatives will review individual records including initial assessments to determine compliance with this section of the regulation. When FBAs are conducted, OMHSAS Licensing Representatives will review the staff file to verify they have a Bureau of Supports for Autism and Special Populations’ FBA training certificate or their BCBA credential documented.Primary Benefit: To ensure assessments are completed in a timely fashion as outlined in the regulation.

Regulation: § 5240.95. Assessment.The assessment shall be reviewed and updated in accordance with § 5240.21(e) and (f). Discussion: OMHSAS interprets the required timeframe outlined in § 5240.21(e) of 12 months to mean 365 days. Managed Care Organizations and/or private insurance organizations may have additional requirements beyond the minimum standards found in § 5240.21(e). For example, assessment updates may be required when there is a change in school setting. OMHSAS encourages IBHS providers to work closely with these organizations to be informed of any such requirements.According to § 5240.97(e), an IBHS provider that provides Group ABA services shall conduct assessments that meet the requirements of § 5240.85 (relating to assessment). This includes the requirement of § 5240.85(f) that states the initial and updated assessments should be signed by the individual qualified to provide behavioral analytics or behavior consultation-ABA services who completed the assessment. This also includes the requirements of § 5240.85(e) that outlines the review and update of assessments.For IBHS agencies providing Group services without providing ABA services, the assessments should be signed by the individual qualified to provide mobile therapy services or behavior consultation services. OMHSAS does not consider the assessment completed until it has been signed by the staff person who completed the assessment. Therefore, the initial assessment should be signed within the timeframe required for the IBHS service (15 days for Individual and 30 days for ABA), and should be updated within 365 days of the signature date on the previous assessment. Inspection Procedures: OMHSAS Licensing Representatives will review individual files and any documents that are included in the updated assessments to determine compliance with this section of the regulation. Primary Benefit: Provides consistency in when the assessment is updated and ensures the individual’s assessed needs are driving treatment.

Regulation: § 5240.96. Individual treatment plan.(a)  A written ITP shall be completed by a graduate-level professional within 30 days after the initiation of group services and be based on the assessment completed in accordance with § 5240.95 (relating to assessment).Discussion: An ITP for Group services, whether or not the services provided include ABA services provision, should be completed within 30 days of the initiation of services. Additionally, according to § 5240.97(e), an IBHS provider that provides Group ABA services shall conduct an ITP that meet the requirements of § 5240.86. Accordingly, an ITP created for Group ABA services should be completed by a staff member who is qualified to BA or BC-ABA services within 30 days of the initiation of services.OMHSAS interprets the completion of an ITP to include the signatures of all required participants, which should be signed off within the 30 calendar day timeframe. The initiation of services is the first day an Individual service is provided. This includes the first day an assessment is conducted. The timeframes used in the IBHS regulations are for calendar days.An IBHS provider who admits a child, youth, or young adult transferred from another IBHS provider may accept and provide services utilizing an ITP completed by the other IBHS provider as long as it is a current ITP (within 6 months of the date the ITP was completed). The IBHS provider should review the ITP to ensure it contains all the required elements of an ITP and is signed by all required participants. If the ITP is deficient in any of the required elements, the provider should develop a new ITP. When ITPs developed by a different IBHS provider are used, the ITP should be updated based on the date the ITP or its most recent update was completed by the previous provider to provide services (the date that all required participants have signed the ITP). When agencies provide Group IBHS services prior to the completion of the ITP, these providers should complete a treatment plan for services as outlined in § 5240.23(b). According to § 5240.97(e), an IBHS provider that provides Group ABA services shall meet the requirements of § 5240.86 (relating to individual treatment plan). This includes the requirement of § 5240.85(a) that states the assessment must be completed by an individual qualified to provide behavioral analytics or behavior consultation-ABA services. Inspection Procedures: OMHSAS Licensing Representatives will review individual charts for ITPs and the dates they were completed and signed. Primary Benefit: To ensure that there is a treatment plan completed early in services, which guides treatment and is based on the assessment.

Regulation: § 5240.96. Individual treatment plan.(b)  The ITP must include the recommendations from the licensed professional who completed the written order for group services in accordance with §§ 1155.32(a)(1) and 1155.34(a)(1) (relating to payment conditions for individual services; and payment conditions for group services).Discussion: 55 Pa Code § 1155.32(a)(1)(iv) presents the information that must appear in a written order. The following information from the written order must be included in the ITP: the maximum number of hours of each service per month, the settings where services may be provided, and the measurable improvements in the identified therapeutic needs that indicate when services may be reduced, changed or terminated. The “maximum number of hours of each service per month” is in reference to each service type provided: BC, MT, BA, BC-ABA and/or BHT or BHT-ABA services. OMHSAS interprets this section of the regulation to require IBHS agencies include this information on the ITP and not included as an attachment to the ITP.Although 55 Pa Code Chapter 1155 is a regulation that outlines requirements for MA payment, providers who do not accept MA should also include the recommendation information as outlined above from the written order in the ITP.According to § 5240.97(e), an IBHS provider that provides Group ABA services shall meet the requirements of § 5240.86 (relating to individual treatment plan). This includes the requirement of § 5240.86(b) that states the individual treatment plan should include the recommendations from the licensed professional who completed the written order for ABA services in accordance with § 1155.33(a)(1). Inspection Procedures: OMHSAS Licensing Representatives will review individual charts for ITPs and compare that to the original written order to ensure that the information is captured. Primary Benefit: To ensure that the treatment recommendations from the written order appear on the ITP. This will help to ensure these recommendations are easily monitored and followed during the ITP review and completion process, or if recommendations were adjusted following an assessment, will serve as a historical account of what was initially recommended.

Regulation: § 5240.96. Individual treatment plan.(c)  The ITP shall be strength-based with individualized goals and objectives to address the identified therapeutic needs for the child, youth or young adult to function at home, school or in the community.Discussion: Strength-based treatment plans focus on the individual’s internal strengths and resourcefulness and not their deficiencies and failures. OMHSAS interprets this section of the regulation to require IBHS agencies to create ITPs which are person-centered and individualized, with goals that address all living environments regardless of the location in which the services are provided. Inspection Procedures: OMHSAS Licensing Representatives will review individual charts and ITPs to determine the ITP is strength-based with individualized goals for the individual to function at home, school or in the community. Primary Benefit: To ensure that treatment is based on the child, youth, or young adult’s strengths and is specifically tailored to their needs.

Regulation: § 5240.96. Individual treatment plan.(d)  The ITP must include the following:   (1)  Specific goals and objectives to address the identified therapeutic needs with definable and measurable outcomes.   (2)  Whether and how parent, legal guardian or caregiver participation is needed to achieve the identified goals and objectives.   (3)  Structured therapeutic activities, community integration activities and individual interventions to address identified therapeutic needs for the child, youth or young adult to function at home, school or in the community.   (4)  Time frames to complete each goal.   (5)  Settings where group services may be provided.   (6)  Number of hours that group services will be provided to the child, youth or young adult.Discussion: Per § 5240.97(e), an IBHS provider that provides group services and ABA services shall also comply with §§ 5240.81—5240.87 (relating to applied behavior analysis). Accordingly, in addition to the content required in this section, an ITP created for an individual receiving group ABA should include the content required in § 5240.86(d).The “number of hours” in subsection (6) can be written monthly or weekly. OMHSAS suggests that group IBHS ITPs additionally include the three-part safety plans as outlined in § 5240.22(d) for Group services not utilizing ABA and § 5240.86(c) for Group services utilizing ABA. Inspection Procedures: OMHSAS Licensing Representatives will review individual charts for ITPs and the presence of each item listed in this section of the regulation. Primary Benefit: To ensure ITPs are detailed and outline a specific service plan for each child, youth, or young adult.

Regulation: § 5240.96. Individual treatment plan.(e)  The ITP shall be developed in collaboration with the child, youth, young adult or parent, legal guardian or caregiver of the child or youth as appropriate.Discussion: OMHSAS interprets this section of the regulation to require IBHS agencies to keep documented evidence of collaboration in the development of the ITP within the individual records. This may include but is not limited to: ITP signatures, contact notes, and progress notes connected to the creation and update of the ITP. Inspection Procedures: OMHSAS Licensing Representatives will review the ITP, contact notes, progress notes and other documents in the individual record to determine compliance with this section of the regulation. Primary Benefit: To ensure individuals receiving services, as well as their caregivers, are involved in the development of their treatment goals.

Regulation: § 5240.96. Individual treatment plan.(f)  The ITP shall be reviewed and updated at least every 6 months or if one of the following occurs:   (1)  The child, youth or young adult has made sufficient progress to require that the ITP be updated.   (2)  The child, youth or young adult has not made significant progress towards the goals identified in the ITP within 90 days from the initiation of the services.   (3)  The youth or young adult requests an update.   (4)  A parent, legal guardian or caregiver of the child or youth requests an update.   (5)  The child, youth or young adult experiences a crisis event.   (6)  The ITP is no longer clinically appropriate for the child, youth or young adult.   (7)  A staff person, primary care physician, other treating clinician, case manager or other professional involved in the child’s, youth’s or young adult’s services provides a reason an update is needed.   (8)  The child, youth or young adult experiences a change in living situation that results in a change of the child’s, youth’s or young adult’s primary caregivers.Discussion: OMHSAS suggests the reason for the ITP update should be documented in the ITP or in a progress note, as this information will illustrate the nature of the ITP update and give clarity to the updated information.Managed Care Organizations and private insurance organizations may have additional requirements beyond the minimum standards found in this section, e.g. ITP updates may be required when there is a change in a school setting. OMHSAS encourages IBHS providers to work closely with these organizations to be informed of any such requirements.OMHSAS interprets subsection (6) to require treatment plan updates to occur when a significant increase or decrease in treatment delivery or significant changes to the individual’s schedule occur which would cause the current treatment goals to no longer be clinically appropriate.  Inspection Procedures: OMHSAS Licensing Representatives will review updated ITPs and accompanying clinical documentation to show the reasons for changes to the ITP to determine compliance with this section of the regulation. Primary Benefit: To ensure ITPs that are guiding treatment are reviewed and updated regularly; or when an update is requested, when a plan-altering life event occurs, or when progress or lack of progress necessitates an ITP update.

Regulation: § 5240.96. Individual treatment plan.(g)  An ITP update must include the elements in subsection (d) and the following:   (1)  A description of progress or lack of progress toward previously identified goals and objectives.   (2)  A description of any new goals, objectives and interventions.   (3)  A description of any changes made to previously identified goals, objective or interventions.   (4)  A description of new interventions to be used to reach previously identified goals and objectives.Discussion: OMHSAS interprets that IBHS agencies should create ITPs with measurable goals and directives in order to objectively identify the progress or lack of progress towards goals and objectives, as required in subsection (1) of this section of the regulation. Inspection Procedures: OMHSAS Licensing Representatives will review individual records to include ITP updates to determine compliance with this section of the regulation. Primary Benefit: To ensure consistency in required elements of the ITP update, the ongoing progress measurement, and changes to the plan occur as needed.

Regulation: § 5240.96. Individual treatment plan.(h)  The ITP and all updates shall be reviewed, signed and dated by the youth, young adult or parent or legal guardian of the child or youth, and the staff person who completed the ITP. Discussion: The initial and updated ITPs should be signed by the youth, young adult or parent or legal guardian of the child or youth, and the staff person who completed the ITP. Per § 5240.97(a), only graduate-level professionals may develop and revise ITPs. OMHSAS suggests that qualifications should be displayed next to the signature as signatures are not always easy to identify If using electronic records, a process for electronic signatures needs to be in place. Electronic signatures and electronic pad signatures are both acceptable, and the use of a PIN is not prohibited. When ITP or updates are created through telehealth, the staff should sign, but the youth, young adult or parent or legal guardian may give verbal consent via telehealth. OMHSAS considers an ITP to be effective on the date that all required signatures have been documented on the ITP. Accordingly, all signatures outlined in this section and in § 5240.96(i) should be documented in the ITP on or before the due date for the ITP (30 days for initial ITP or 180 days for an ITP update). For example, an IBHS provider should have the youth, young adult or parent or legal guardian of the child or youth, the staff member who completed the ITP, and the individual who meets the qualifications of a clinical director (as outlined in § 5240.96(i)) complete the initial ITP and all sign within the required timeframe. The updated ITP should be signed by those required in this section and in § 5240.96(i) within 6 months (180 days) of the final required signature included in the previous ITP. Inspection Procedures: OMHSAS Licensing Representatives will review initial and updated ITPs for signatures and dates, and/or documentation of participation in the ITP process to determine compliance with this section of the regulation. Primary Benefit: To ensure youth, young adult or parent or legal guardian of the child or youth, and the qualified staff members have documentation to verify their involvement in the creation of the initial and updated ITPs.

Regulation: § 5240.96. Individual treatment plan.(i)  The ITP and all updates shall be reviewed, signed and dated by an individual who meets the qualifications of a clinical director in § 5240.12 (relating to staff qualifications).Discussion: OMHSAS suggests that title/position should be displayed next to the signature as signatures are not always easy to identify. If the signature is of an individual who meets qualification requirements but is not acting in the role of the clinical director, it is recommended to identify the qualification of this staff member as “clinical director qualified”.If the signature is of an individual who meets qualification requirements but is not acting in the role of the clinical director, it is recommended to identify the qualification of this staff member as “clinical director qualified”. OMHSAS interprets this section to require the ITP and updates created by an individual who meets qualifications but is not acting in the role of a clinical director to additionally be signed by another staff member who meets the qualifications of a clinical director. Additionally, OMHSAS suggests that an additional staff who meets the qualification of a clinical director, when possible, signs the ITP and updates when they are created by the staff acting in the role of the clinical director.According to § 5240.97(e) (relating to group services provision), an IBHS provider that provides Group ABA services shall meet the requirements of § 5240.86 (relating to individual treatment plan). This includes the requirement of § 5240.86(i) that states the individual treatment plan and updates should be reviewed, signed and dated by an individual who meets the qualifications of a clinical director in § 5240.81 (relating to staff qualifications for ABA services). OMHSAS considers an ITP to be effective on the date that all required signatures have been documented on the ITP. Accordingly, all signatures outlined in this section and in § 5240.96(h) should be documented in the ITP on or before the due date for the ITP (30 days for initial ITP or 180 days for an ITP update). For example, an IBHS provider should have the youth, young adult or parent or legal guardian of the child or youth, the staff member who completed the ITP (as outlined in § 5240.96(h)), and the individual who meets the qualifications of a clinical director complete the initial ITP and all sign within the required timeframe. The updated ITP should be signed by those required in this section and in § 5240.96(h) within 6 months (180 days) of the final required signature included in the previous ITP. Inspection Procedures: OMHSAS Licensing Representatives will review ITPs for signatures of staff qualified to be the clinical director and dates to determine compliance with this section of the regulation. Primary Benefit: To ensure a staff member qualified to be a clinical director is reviewing ITPs and participating in the ITP process.

Regulation: § 5240.97. Group services provision.(a)  A graduate-level professional may provide individual, group and family psychotherapy; design of psychoeducational group activities; clinical direction of services to a child, youth or young adult; create and revise the ITP; oversee implementation of the ITP and consult with the child’s, youth’s or young adult’s treatment team regarding the ITP.Discussion: According to § 5240.97(e), an IBHS provider that provides Group ABA services shall meet the requirements of § 5240.81 (relating to staff qualifications for ABA services). Accordingly, any staff providing graduate-level professional services in a program providing Group ABA services must meet qualifications to provide behavioral analytic services or behavior consultation-ABA services.IBHS agencies providing Group services without utilizing ABA services may consider any staff member who is qualified under § 5240.91(a)(1)-(4) to be a graduate-level professional. Inspection Procedures: OMHSAS Licensing Representatives will review job descriptions, documents that verify qualifications are met, supervision records, individual records and may interview graduate-level staff to ensure compliance with this section of the regulation. Primary Benefit: To ensure appropriately credentialed staff are responsible for the development and provision of Group services.

Regulation: § 5240.97. Group services provision.(b)  An individual who meets the qualifications to provide BHT services or BHT-ABA services may assist with conducting group psychotherapy, facilitate psychoeducational group activities and implement the child’s, youth’s or young adult’s ITP.Discussion: According to § 5240.97(e), an IBHS agency that provides Group ABA services shall meet the requirements of § 5240.81 (relating to staff qualifications for ABA services). Accordingly, any staff providing BHT-level services in a program providing Group ABA services must meet qualifications to provide BHT-ABA services.IBHS agencies providing Group services without utilizing ABA services may consider any staff member who is qualified under § 5240.91(b)(1) or § 5240.91(b)(2) for this service. Inspection Procedures: OMHSAS Licensing Representatives will review job descriptions, documents that verify qualifications are met, supervision records, individual records and may interview staff to ensure compliance with this section of the regulation. Primary Benefit: To ensure appropriately credentialed staff may assist with conducting group psychotherapy, facilitate psychoeducational group activities, and implementation of the ITP.

Regulation: § 5240.97. Group services provision.(c)  Group services shall be structured to address the goals and objectives identified in the child’s, youth’s or young adult’s ITP.Discussion: OMHSAS interprets the requirement that ITP goals are to be individualized to mean Groups should be organized in such a manner that individuals with similar/compatible goals for the time they are in group. Consideration of each group member’s ITP goals is critical when an IBHS provider develops Group psychotherapy and psychoeducational activities. Inspection Procedures: OMHSAS Licensing Representatives will review treatment plans, assessments, group notes, and may interview staff as needed to determine compliance with this section of the regulation. Primary Benefit: To ensure Group services are appropriate to meet each individual’s treatment goals.

Regulation: § 5240.97. Group services provision.(d)  Group services can be provided in a school, community setting or community like setting.Discussion: In order to verify that this section of the regulation is met, OMHSAS interprets this section to require the setting in which Group services are provided to be indicated on the group session note. Inspection Procedures: OMHSAS Licensing Representatives will review treatment plans, assessments, group notes, and may interview staff as needed to determine compliance with this section of the regulation. Group services should be provided at a consistent location and time. Primary Benefit: To ensure Group services are provided in settings as outlined in the regulation.

Regulation: § 5240.97. Group services provision.(e)  An IBHS agency that provides group services and ABA services shall also comply with §§ 5240.81—5240.87 (relating to applied behavior analysis).Discussion: §§ 5240.81—5240.83 outlines qualification, supervision, and training requirements that shall be met for all staff who provide ABA services in a group setting, as well as requirements of the clinical and administrative directors who oversee these services.§§ 5240.84—5240.87 outlines service initiation, assessment, ITP, and service provision requirements that shall be met by all IBHS agencies that provide ABA services in a group setting.OMHSAS interprets this section of the regulation to be applicable only to IBHS agencies that conduct ABA services in a group setting. IBHS agencies that separately provide ABA services and Group services which do not utilize ABA do not need to apply the ABA requirements outlined in this section to the Group service not utilizing ABA.  Inspection Procedures: OMHSAS Licensing Representatives will review staff qualifications, supervision records, training records, treatment plans, assessments, group notes, and may interview staff as needed to determine compliance with this section of the regulation.  Primary Benefit: To ensure ABA services provided in a group setting meet the requirements to provide ABA services.

Regulation: § 5240.97. Group services provision.(f)  A graduate-level professional shall be present while group services are being provided.Discussion: OMHSAS interprets the term “present” in this section to mean that the graduate-level professional is physically located at the facility for services as needed, but they are not required to be present in the room where services are provided at all times during service provision. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures, group notes, supervision notes and may review daily schedules or interview staff members to determine compliance with this section of the regulation. Primary Benefit: To ensure appropriate supervision is provided to those facilitating Group services.

Regulation: § 5240.98. Requirements for group services in school settings.A licensed IBHS agency that provides group services and identified a school as a location where services will be provided in its approved service description shall meet the following requirements:   (1)  Have a written agreement with the authorized representative for each school location in which it provides group services that includes the following:     (i)     Identification of the IBHS provider’s and the school’s lead contacts and their contact information.     (ii)    Delineation of roles and responsibilities of the school and the IBHS provider staff.     (iii)   Description of how the school and IBHS provider staff will collaborate during the provision of group services in the school.     (iv)   A requirement for a meeting at least every 6 months between IBHS provider staff and school administration to review performance, collaboration issues and the written agreement.     (v)    Crisis management protocols.     (vi)   Procedures for school staff to refer students for group services.     (vii)   Identification of the space and equipment allocated for use by IBHS provider staff.     (viii)  Process for revising or updating the written agreement.Discussion: Written agreements should be held for each school location in which an IBHS provider provides Group services. An authorized representative of the school may be any individual designated by the school as a representative. In order to verify that the requirement outlined in (iv) is met, OMHSAS interprets this section to require IBHS agencies to keep records of meetings held with the school administration. OMHSAS suggests that the documentation includes the date of the meeting and the items reviewed in the course of the meeting. When IBHS agencies have written agreements with multiple school locations that operate under the authority of one school administration, a separate meeting for each location where services are provided is necessary. Inspection Procedures: OMHSAS Licensing Representatives will review written agreements, and policies and procedures to ensure compliance with this section of the regulation. Primary Benefit: To ensure collaboration is occurring between the IBHS provider and the school where Group services are provided.

Regulation: § 5240.98. Requirements for group services in school settings.A licensed IBHS provider that provides group services and identified a school as a location where services will be provided in its approved service description shall meet the following requirements:   (2)  IBHS provider and school staff involved with the child, youth or young adult receiving group services shall meet at least every 6 months to discuss the student’s behavioral health services and progress related to school performance.     (i)    A youth, young adult or parent or legal guardian of the child or youth shall be invited to participate in the meeting.     (ii)   Other professionals as requested by a youth, young adult or parent or legal guardian of the child or youth shall be invited to participate in the meeting.Discussion: OMHSAS interprets this section to require that IBHS agencies hold meetings to individually discuss every youth and young adult served in the Group IBHS provider. Accordingly, OMHSAS suggests IBHS agencies develop a system to track the dates of all meetings to ensure they are conducted timely. OMHSAS suggests IBHS agencies document attempts to invite those outlined in this section and should document when a member outlined in this section is unable or refuses to attend. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures outlining this process, meeting notes, and documentation that verifies outreach attempts to determine compliance with this section of the regulation. Primary Benefit: To ensure regular meetings are held between the school and the IBHS provider to evaluate the student’s behavioral health services and school performance, and to assure relevant parties are invited to attend.

Regulation: § 5240.98. Requirements for group services in school settings.A licensed IBHS provider that provides group services and identified a school as a location where services will be provided in its approved service description shall meet the following requirements:   (3)  An IBHS provider shall document the outcome of the meeting and include the following:     (i)     Attendance.     (ii)    Date of meeting.     (iii)   Summary of the discussion.     (iv)   Recommendations for a change in group service participation if  discussed.     (v)    Reason a meeting was not convened as required.Discussion: OMHSAS interprets this section to require documentation outlined in this section to be stored in the individual’s records because the meeting referenced in this section is specific to the individual. Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures outlining this process, meeting notes, the individual record, and documentation that verifies outreach attempts to determine compliance with this section of the regulation. Primary Benefit: To ensure collaboration with all members on the treatment team and maintain documentation that can be used to verify IBHS provider conducted meetings are required by the regulation.

Regulation: § 5240.98. Requirements for group services in school settings.A licensed IBHS provider that provides group services and identified a school as a location where services will be provided in its approved service description shall meet the following requirements:   (4)  An IBHS provider providing group services in school settings shall keep the child’s, youth’s or young adult’s records in accordance with § 5240.41 (relating to individual records).Discussion: OMHSAS suggests IBHS agencies should discuss the regulation’s documentation requirements when negotiating the written agreement with the school.  § 5240.41(a) requires the individual record include identifying information, written order, assessment(s), presenting problems, ITP and any ITP updates, treatment plan if services provided before the creation of ITP, documentation of coordination with other services and community supports, documentation of each service provided, explanation if services were not provided in accordance with ITP and written order, consent to treatment and consent to release information, discharge summary and documentation of any use of manual restraint.§ 5240.41(b) requires the record be legible, reviewed for quality by the administrative director or clinical director or designated quality improvement staff within 6 months of initial entry and new additions to the record reviewed on an annual basis. § 5240.41(c) requires records to be maintained for 4 years after the last date of service. Inspection Procedures: OMHSAS Licensing Representatives will review individual records and may interview staff to determine compliance with this section of the regulation. Primary Benefit: To ensure records include information of importance in the provision of service, and records across IBHS providers include consistent documentation. Additionally, to ensure provider management is reviewing records for quality and that records are legible, and to ensure records are complete and stored in the event they are needed.

Regulation: § 5240.98. Requirements for group services in school settings.A licensed IBHS provider that provides group services and identified a school as a location where services will be provided in its approved service description shall meet the following requirements:   (5)  An ITP for group services provided in school settings shall be developed in accordance with § 5240.96 (relating to individual treatment plan) and must include the following:     (i)     Continuity of services when school is not in session.     (ii)    Interventions that specifically address the child’s, youth’s or young adult’s functioning in school.     (iii)   Input from the teachers and guidance counselors directly involved with the child, youth or young adult receiving group services.Discussion: None. Inspection Procedures: OMHSAS Licensing Representatives will review individual treatment records including ITPs, assessments, written orders, contact notes, and progress notes and may interview staff members to determine compliance with this section of the regulation. Primary Benefit: To ensure additional considerations relevant to school provision of services are taken into account in the ITPs for school-based Group IBHS services.

Regulation: § 5240.98. Requirements for group services in school settings.A licensed IBHS provider that provides group services and identified a school as a location where services will be provided in its approved service description shall meet the following requirements:   (6)  An IBHS provider that provides group services and ABA services and provides the services in school settings shall comply with §§ 5240.81—5240.87 (relating to applied behavior analysis).Discussion: §§ 5240.81—5240.83 outlines qualification, supervision, and training requirements that shall be met for all staff who provide ABA services in a group setting, as well as requirements of the clinical and administrative directors who oversee these services.§§ 5240.84—5240.87 outlines service initiation, assessment, ITP, and service provision requirements that shall be met by all IBHS providers that provide ABA services in a group setting.OMHSAS interprets this section of the regulation to be applicable only to IBHS agencies that conduct ABA services in a Group setting. IBHS agencies that separately provide ABA services and Group services which do not utilize ABA do not need to apply the ABA requirements outlined in this section to the Group service not utilizing ABA.  Inspection Procedures: OMHSAS Licensing Representatives will review staff qualifications, supervision records, training records, treatment plans, assessments, group notes, and may interview staff as needed to determine compliance with this section of the regulation.  Primary Benefit: To ensure ABA services provided in a Group setting meet the requirements to provide ABA services.

EVIDENCE-BASED THERAPY

Regulation: § 5240.101. EBT initiation requirements.(a)  An IBHS provider shall use individual services, ABA services or group services to provide EBT to a child, youth or young adult in accordance with a written order under § 1155.35(a)(1) (relating to payment conditions for EBT delivered through individual services, ABA services or group services). Discussion: The following EBT service models are currently approved through DHS to be provided through the IBHS regulation: • Multisystemic Therapy (MST)• MST for problematic sexual behavior (MST-PSB)• MST-psych• Functional Family Therapy (FFT)• PCIT in a licensed location that meets all the physical site requirements of the Model Note: all currently approved EBT services are provided through Individual services. Accordingly, IBHS agencies who provide EBT services should have Individual services designated on their license.  Inspection Procedures: OMHSAS Licensing Representatives will review the written order and the individual records to ensure services are provided in accordance with the written order to determine compliance with this section of the regulation. Primary Benefit: To ensure services are provided in accordance with the written order as this provides documentation that the services are medically necessary and provides the framework of the therapeutic services the child requires.

Regulation: § 5240.101. EBT initiation requirements.(b)  Prior to the initiation of EBT, the IBHS provider shall obtain written consent to receive the EBT identified in the written order from the youth, young adult or parent or legal guardian of a child or youth.Discussion: OMHSAS suggests that the consent to receive services either directly includes the recommendation(s) found in the written order or refers the family to the written order. This way, their consent to those specified services is documented. For the purpose of the required timing, OMHSAS defines the initiation of services as the first day an Individual service is provided. This includes the first day an assessment is conducted. Inspection Procedures: OMHSAS Licensing Representatives will review the consent form and individual record documents to identify the date of the initiation of services to determine compliance with this section of the regulation. Primary Benefit: To ensure that the youth, young adult or parent or legal guardian are consenting to the services outlined in the written order prior to the initiation of these services.

Regulation: § 5240.102. Assessment and individual treatment plan.(a)  A face-to-face assessment shall be completed by staff with the qualifications required by the EBT for a child, youth or young adult within 15 days of the initiation of the service in accordance with §§ 5240.21(b)—(d) and (f), 5240.85(b)—(d) and (f) or 5240.95(a) (relating to assessment) and prior to completing the ITP.Discussion: As required by sections §§ 5240.21(c)(7) and 5240.85(c)(6), the child should be assessed across the home, school, and other community settings. OMHSAS interprets the initiation of services to mean the first day an EBT service is provided. This includes the first day an assessment is conducted. The timeframes used in the IBHS regulations are for calendar days.An IBHS provider providing EBT services may utilize assessments specific to the model. However, these assessment tools must meet the minimum requirements of the IBHS service utilized (i.e. Individual, Group, or ABA). In instances where the assessment tool developed for the EBT does not cover all the required content of the IBHS assessment OMHSAS suggests that the tool is amended, or an attachment is created. This is to ensure it contains all the additional required content.  Inspection Procedures: OMHSAS Licensing Representatives will review individual records including initial assessments to determine compliance with this section of the regulation. Primary Benefit: To ensure assessments are completed in a timely fashion as outlined in the regulation.

Regulation: § 5240.102. Assessment and individual treatment plan.(b)  The assessment shall be reviewed and updated in accordance with §§ 5240.21(e) and (f), 5240.85(e) and (f) or 5240.95(b).Discussion: §§ 5240.21(e) and (f), 5240.85(e) and (f) require assessments to be updated every 12 months or if one of the following occurs:    (1)  A parent, legal guardian or caregiver of the child or youth requests an update.   (2)  The youth or young adult requests an update.   (3)  The child, youth or young adult experiences a change in living situation that results           in a change of the child’s, youth’s or young adult’s primary caregivers.   (4)  The child, youth or young adult has made sufficient progress to require an update.   (5)  The child, youth or young adult has not made significant progress towards the           goals identified in the ITP within 90 days from the initiation of the services.   (6)  The child, youth or young adult experiences a crisis event.   (7)  A staff person, primary care physician, other treating clinician, case manager or          other professional involved in the child’s, youth’s or young adult’s services provides          a reason an update is needed.Managed Care Organizations and/or private insurance organizations may have additional requirements beyond the minimum standards found in this section. For example, assessment updates may be required when there is a change in the school setting. OMHSAS encourages IBHS providers to work closely with these organizations to be informed of any such requirements. Inspection Procedures: OMHSAS Licensing Representatives will review individual files and any documents that are included in the updated assessments to determine compliance with this section of the regulation. Primary Benefit: Provides consistency in when the assessment is updated and ensures the individual’s assessed needs are driving treatment.

Regulation: § 5240.102. Assessment and individual treatment plan.(c)  A written ITP shall be completed, reviewed and updated in accordance with §§ 5240.22, 5240.86 or 5240.96 (relating to individual treatment plan). Discussion: EBT provided through Individual services, and Group IBHS services utilizing Individual services, should have the initial ITP completed within 30 days of the initiation of service. EBT provided through ABA services, and Group services utilizing ABA services, should have the initial ITP completed within 40 days of the initiation of services. §§ 5240.22(f), 5240.86(f), and 5240.96(f) similarly outline that ITPs should be updated at least every 6 months or if one of the following occurs: The child, youth or young adult has made sufficient progress to require that the ITP be updated.The child, youth or young adult has not made significant progress towards the goals identified in the ITP within 90 days from the initiation of the services.   (3)  The youth or young adult requests an update.   (4)  A parent, legal guardian or caregiver of the child or youth requests an update.   (5)  The child, youth or young adult experiences a crisis event.   (6)  The ITP is no longer clinically appropriate for the child, youth or young adult.   (7)  A staff person, primary care physician, other treating clinician, case manager or          other professional involved in the child’s, youth’s or young adult’s services provides          a reason an update is needed.   (8)  The child, youth or young adult experiences a change in living situation that results          in a change of the child’s, youth’s or young adult’s primary caregivers. OMHSAS considers an ITP to be effective on the date that all required signatures have been documented on the ITP. Accordingly, the youth, young adult or parent or legal guardian of the child or youth, or young adult, the staff member who completed the ITP, and the individual who meets the qualifications of a clinical director all sign the ITP before the due date for the initial ITP (30 days for Individual services and Group services provided through Individual services, and 45 days for ABA services and Group services provided through ABA) or ITP update completion (180 days). The updated ITP should be signed by those outlined above within 6 months (180 days) of the date the final required signature was included in the previous ITP.OMHSAS suggests the reason for the ITP update be documented in the ITP or in a progress note, as this information will illustrate the nature of the ITP update and give clarity to the updated information.OMHSAS interprets subsection (6) to require treatment plan updates to occur when a significant increase or decrease in treatment delivery or significant changes to the individual’s schedule occur which would cause the current treatment goals to no longer be clinically appropriate.  Inspection Procedures: OMHSAS Licensing Representatives will review updated ITPs and accompanying clinical documentation to show the reasons for changes to the ITP to determine compliance with this section of the regulation. Primary Benefit: To ensure ITPs that are guiding treatment are reviewed and updated regularly; or when an update is requested, when a plan-altering life event occurs, or when progress or lack of progress necessitates an ITP update.

Regulation: § 5240.103. Requirements for EBT delivered through individual services, ABA services or group services.(a)  An IBHS provider or the individual providing the EBT shall have a certification or licensure from the National certification organization or entity that developed or owns the EBT.Discussion: The National certification organization specific to the EBT model the IBHS operates under may have its own requirements in addition to the requirements found in this regulation. It is important for IBHS agencies providing EBT services to adhere to all requirements of the National certification organization. Please note: representatives of the National certification organization may participate in licensing reviews. Inspection Procedures: OMHSAS Licensing Representatives will review the certification or license issued by the National certification organization that oversees the model of EBT the IBHS provider operates under, and any documentation that outlines the collaboration between the two entities, to determine compliance with this section of the regulation. Primary Benefit: To ensure the IBHS provider meets the regulatory requirements and any additional requirements of the EBT model.  This section also ensures the quality of the service and compliance with the EBT model.

Regulation: § 5240.103. Requirements for EBT delivered through individual services, ABA services or group services. (b)  An IBHS provider shall ensure that EBT is provided by staff that meet the qualifications and receive supervision as set forth in the EBT. Discussion: An IBHS provider that provides EBT services does not need to follow the qualification and supervision requirements outlined in the IBHS regulation for the staff who provide the EBT services if the EBT has defined staff qualifications. In these cases, the provider should follow qualification and supervision requirements as set forth by the National certification organization that oversees the EBT model. Inspection Procedures: OMHSAS Licensing Representatives will review the program information form, training records, supervision documents to determine compliance with this section of the regulation.  Primary Benefit: To ensure the IBHS provider meets the regulatory requirements and any additional requirements of the EBT model.  This section also ensures the quality of the service and validity of the model.

Regulation: § 5240.103. Requirements for EBT delivered through individual services, ABA services or group services. (c)  An IBHS provider that is using an EBT shall have written policies and procedures to measure the following:   (1)  Adherence to the implementation of the specific EBT.   (2)  Outcomes of the EBT that incorporate review standards associated with the EBT.Discussion: None.  Inspection Procedures: OMHSAS Licensing Representatives will review policies and procedures against review standards associated with the EBT, and outcome measures to determine compliance with this section of the regulation. Primary Benefit: To ensure the IBHS provider meets the regulatory requirements and any additional requirements of the EBT model.  This section also ensures the quality of the service and validity of the model.

Regulation: § 5240.103. Requirements for EBT delivered through individual services, ABA services or group services.(d)  An IBHS provider using an EBT shall continuously monitor the fidelity to the EBT.Discussion: IBHS agencies providing an EBT service are responsible for keeping documentation consistent to with the EBT to ensure fidelity to the model.  Inspection Procedures: OMHSAS Licensing Representatives will review monitoring documentation to determine compliance with this section of the regulation. Primary Benefit: To ensure the IBHS provider is continually monitoring the provision of EBT service to assure that fidelity is met.

Regulation: § 5240.103. Requirements for EBT delivered through individual services, ABA services or group services.(e)   An IBHS provider shall ensure that procedures related to and decisions about continuing services and discharge are made in accordance with the specific EBT.Discussion: OMHSAS suggests that IBHS agencies providing EBT services consult with the National certification organization and/or the EBT model documentation to ensure the continuity of service and that discharges are appropriately made. OMHSAS further suggests that collaboration with the National certification organization be documented. Inspection Procedures: OMHSAS Licensing Representatives will review individual records to include P&Ps, contact notes, progress notes, treatment plans, team meetings, and discharge summaries to determine compliance with this section of the regulation.   Primary Benefit: To ensure the IBHS provider is continually monitoring the provision of EBT service to assure that fidelity is met.

Regulation: § 5240.103. Requirements for EBT delivered through individual services, ABA services or group services.(f)  An IBHS provider that does not meet the standards of the EBT it provides shall:   (1)  Have a corrective action plan that is approved by the National certification organization or the Department.   (2)  Track the corrective action plan to ensure that the plan has been implemented.   (3)  Complete the corrective action plan to meet the standards of the EBT within the time frame identified in the corrective action plan.Discussion: OMHSAS suggests that discussion with the National certification organization should be documented. OMHSAS interprets the “full access” requirement outlined in 55 Pa Code Chapter 20.34 to require the corrective action plan, tracking documents, and documentation outlining the completion of the plan to be made available for review by the OMHSAS Licensing Representative. Inspection Procedures: OMHSAS Licensing Representatives will review all documentation related to a corrective action plan approved by the National certification organization or the Department, and any documentation relevant to the corrective action plan to determine compliance with this section of the regulation. Primary Benefit: To ensure that IBHS agencies that do not meet the EBT standards follow through a corrective action plan approved by the National certification organization or the Department.

WAIVERS

Regulation: § 5240.111. Waivers.(a)  An IBHS provider may submit a written request to the Department for a waiver of a specific requirement in this chapter.Discussion: Instructions on how to submit a request for a waiver may be found in Attachment 2, Information and Guidelines for  Providers Regarding Waiver Submission, of the OMHSAS Memorandum published March 24, 2022. IBHS agencies must utilize the OMHSAS Request For Waiver Form, available as Attachment 1 to the OMHSAS Memorandum.Waivers are typically approved in timeframes that match the timeframe found on the license to provide IBHS services. For example, if an IBHS provider requests a waiver in March and their current license expires in November, an approved waiver would cover the period from March to November.As outlined in OMHSAS-16-03: Revised Procedure for Waiver of Office of Mental Health and Substance Abuse Services (OMHSAS) Program Regulations and Standards, requests for a renewal of a waiver must be submitted by 60 days prior to the license renewal or the approved waiver’s expiration date, whichever is earlier. Failure to submit within that timeframe may result in a citation.  A provider may apply for a waiver as part of the application process for an initial license. Inspection Procedures: OMHSAS Licensing Representatives will review and process waiver request documentation to determine compliance with this section of the regulation. Primary Benefit: Ensures providers have the right to request the Department for a waiver of specific requirements outlined in the chapter.

Regulation: § 5240.111. Waivers.(b)  The Department may grant a waiver unconditionally or subject to conditions that shall be met. The Department may revoke a waiver if conditions required by the waiver are not met.Discussion: Conditions added by the Department in the approval of the waiver will appear in the waiver approval letter issued by OMHSAS. If the IBHS provider has questions regarding the conditions, the provider should contact their OMHSAS Licensing Representative. Inspection Procedures: OMHSAS Licensing Representatives will review the waiver approval letter to determine if conditions were applied to the waiver approval and will review all documents needed to verify conditions are met. OMHSAS Licensing Representatives may also interview staff members to determine compliance with this section of the regulation. Primary Benefit: To provide OMHSAS with a mechanism for additional oversight of waivers as needed, and to ensure IBHS agencies meet the conditions.

Regulation: § 5240.111. Waivers.(c)  A waiver request will be granted only in exceptional circumstances and if the following are met:   (1)  The waiver does not jeopardize the health and safety of the children, youth or young adults served by the IBHS provider.   (2)  The waiver will not adversely affect the quality of services provided by the IBHS provider.   (3)  The intent of the requirement to be waived will still be met.   (4)  Children, youth or young adults will benefit from the waiver of the requirement.   (5)  The waiver does not violate a Federal or State statute or regulation.Discussion: The OMHSAS Request For Waiver Form, available as Attachment 1 to the OMHSAS Memorandum published March 24, 2022, contains sections to document these requirements that must be met. Inspection Procedures: OMHSAS Licensing Representatives will review waiver applications and any documentation connected with the waiver to determine compliance with this section of the regulation. Primary Benefit: Ensures the health and safety, quality of services, and intent of requirements are not sacrificed by the approval of the waiver. Additionally, it ensures agencies consider the benefit that the waiver will provide to the individuals and consider relevant Federal and State statutes and regulations.

PART 3:

Relevant Bulletins

OMHSAS-20-07 PRIOR-AUTHORIZATION OF INTENSIVE BEHAVIORAL HEALTH SERVICES (IBHS)

Bulletin Section: SCOPE: This bulletin applies to all providers who render Intensive Behavioral Health Services (IBHS) to children, youth, and young adults under 21 years of age who receive services in the Medical Assistance (MA) Provider fee-for-service (FFS) delivery system. This bulletin does not apply to services provided in the managed care delivery system. Providers rendering services in the managed care delivery system should address questions about authorization of IBHS to the appropriate managed care organization.

Bulletin Section: DISCUSSION: The following IBHS require prior authorization:  1. Individual Services: BHT services 2. ABA: Assistant BC-ABA and BHT-ABA services 3. Group Services

Bulletin Section: PROCEDURE:The Handbook for Prior Authorization of Intensive Behavioral Health Services (IBHS) Rendered in the Fee-for-Services Delivery System provides instructions for submitting prior authorization requests for IBHS. As required by 55 Pa. Code § 1101.67(a), providers should follow the instructions in the handbook for submitting prior authorization requests.

OMHSAS-21-22 REVISED GUIDELINES FOR THE DELIVERY OF BEHAVIORAL HEALTH SERVICES THROUGH TELEHEALTH

Bulletin Section: High Intensity ServicesSome behavioral health services may be appropriate to be provided primarily through telehealth, while other services will require ongoing in-person delivery for a significant portion of or all of the services. Providers and practitioners should carefully consider the clinical appropriateness of telehealth delivery for such services, including, but not limited to: Partial Hospitalization, Intensive Behavioral Health Services (IBHS), Family Based Mental Health, Assertive Community Treatment (ACT), or if the beneficiary is in a residential facility or inpatient setting.

OMHSAS-22-03 UPDATED: PROVISION OF ONE-TO-ONE INTENSIVE BEHAVIORAL HEALTH SERVICES IN A LICENSED LOCATION

Bulletin Section: DISCUSSION: In some instances, the provision of one-to-one Individual services or ABA services in a child’s, youth’s, or young adult’s natural environment may not meet the child’s, youth’s or young adult’s behavioral health needs. In such instances it may be clinically appropriate to provide medically necessary Individual services or ABA services at a provider’s licensed location.

Bulletin Section: DISCUSSION: Because these are services that are being provided to children, youth or young adults, the areas in the provider location where services are being provided should be age and developmentally appropriate and community like. A community like setting is a setting that simulates a natural and normal setting for a child, youth or young adult. Services provided at a provider’s location are sometimes referred to as center-based services.

Bulletin Section: DISCUSSION: One-to-one Individual services and ABA services at a center may be provided for the amount of time required to enable the child, youth, or young adult to acquire skills that will allow the child, youth, or young adult to transition to services in the home or community or for a longer period of time if receiving services at a center is clinically appropriate for a child, youth or young adult.

Bulletin Section: DISCUSSION: Even if services will be provided at a center, the assessment should be conducted in the child’s, youth’s or young adult’s natural environment so that the child’s, youth’s or young adult’s strengths and needs across home, school and community settings can be documented and the assessment can be used to build a treatment plan that is responsive to the needs of each child, youth, or young adult in the home, school and community.

Bulletin Section: PROCEDURE: Providers who want to provide one-to-one Individual services or ABA services at a center should include the information identified in Attachment A in their IBHS service description.

Bulletin Section: OMHSAS-22-03 – Attachment A: Additional Information for Service Descriptions for Intensive Behavioral HealthService (IBHS) Agencies That Intend to Provide One-to-One Services in a Center 1. Provider’s Name2. IBHS License Number, if licensed3. Location of Center4. Describe the target population served. At a minimum include:a. Age range servedb. Presenting issues, which may include specific diagnosesc. Admission criteria, including the clinical rational for providing center-basedservicesd. Exclusionary criteria5. Describe the services that will be provided. At a minimum include:a. The type of IBHS that will be provided (individual services, and/or ABAservices)b. Opportunities for interaction with peersc. Types of interventions that will be usedd. Description of a typical daily treatment session for a child, youth, or youngadult, includingi. Length of time the child, youth or young adult will be receiving servicesat the centerii. Amount to time spent on each provider, activity or intervention,including any group activitiesiii. Time spent in non-treatment activities such as napsNote: Provider can submit a sample schedule(s)6. Describe how families will be involved with the services provided at the center,including caregiver training.7. Describe how a child’s, youth’s or young adult’s progress will be monitored andhow it will be determined when the one-to-one center-based services shouldtransition to services in the child’s, youth’s or young adult’s home and communityor to group services.

PART 4:

Additional Resources

Bureau of Equal Opportunity 

Civil Rights Compliance – General Process

Civil Rights Compliance (CRC) forms must be submitted, as outlined in this section, by all provider agencies who are submitting an initial application or annual license renewal application. 

Providers seeking a new license will utilize a CRC form (HS 2126). This form must be included in the packet submitted as part of any new license request. The new application, supporting documents, and CRC form must be emailed to: RA-PWLICADOMHSASPRO@pa.gov. The CRC form can be found at: App for License (pa.gov) or https://www.dhs.pa.gov/providers/Clearances-and-Licensing/Pages/App-for-License.aspx.

For license renewals, a provider will now submit a CRC Attestation form (HS 2125).  The Attestation form must be submitted as part of a renewal licensing application. The renewal notice will still be sent out 130 days prior to expiration.  The renewal application and Attestation must be emailed to: RA-PWLICADOMHSASPRO@pa.gov. The CRC form can be found at: App for License (pa.gov) or https://www.dhs.pa.gov/providers/Clearances-and-Licensing/Pages/App-for-License.aspx

The issuance of the new license or renewal license will indicate that your CRC form or CRC Attestation form submission was approved. If there are issues/questions on the submitted CRC or Attestation form, a staff member from DHS will contact you. Please see the “Bureau of Equal Opportunity Civil Rights Compliance – Additional Instructions” section below for additional instructions on how to successfully complete the forms.

Note: At the discretion of program offices you can amend the communication to allow legal entities to submit an attestation form for multiple locations and include attachments of additional locations.

Bureau of Equal Opportunity 

Civil Rights Compliance – Additional Instructions

1. When sending the CRC form or the CRC Attestation form please send as a PDF.  Please do NOT send as a secure file, secure email, or link to a secure portal to retrieve the document. We are unable to access those forms and they will be returned. When emailing the forms for submission:

1. Use the following naming convention in the subject line when submitting Renewal HS2125:
   1. Attestation – OMHSAS – [Name of Facility or Agency] – [License number or APP number if assigned]
2. Use the following naming convention in the subject line when submitting a new application HS2126
   1. New – OMHSAS – [Type of Service] – [Name of Facility or Agency]
3. In OMHSAS there are providers who have one license that covers multiple locations.  In this case, you only need to submit one form and list the addresses of each satellite site/location that falls under that license.

3. If in the past, you completed the Civil Rights Compliance Questionnaire (CRCQ) annually as part of the renewal license process, you will need to complete the Civil Rights Attestation (HS2125) when you receive your next notice to complete the renewal application process.

4. Please ensure that the “Non-Discrimination in Employment” policy statement and the “Non-Discrimination in Services” policy statements issued by your facility contain updated contact information (as indicated below). If this administrative update is the only change that has occurred since the facility’s last license was issued, it is not necessary to provide updated copies to the Department as part of Form HS 2125. 

Commonwealth of Pennsylvania

Department of Human Services

BEO/Office of Civil Rights Compliance

Room 225, Health & Welfare Building

P.O. Box 2675 Harrisburg, PA 17120

Inquiries: (717) 787-1127

Email: RA-PWDHSCivilRights@pa.gov

Office for Civil Rights

U.S. Department of Health and Human Services Centralized Case Management Operations 200 Independence Avenue, S.W.

Room 509F HHH Bldg

Washington, D.C. 20201

Customer Response Center: (800) 368-1019 TDD: (800) 537-7697

https://www.hhs.gov/ocr/complaints

U.S. Equal Employment Opportunity Commission 801 Market Street, Suite 1000

Philadelphia, PA 19107-3126

Inquiries: (800) 669-4000

https://www.eeoc.gov/federal-sector/overview- federal-sector-eeo-complaint-process

Pennsylvania Human Relations Commission 333 Market Street, 8th Floor

Harrisburg, PA 17101

https://www.phrc.pa.gov/File-a-complaint

Inquiries: (717) 787-4410

Electronic Record Keeping

Many human services facilities and agencies licensed by the Department of Human Services maintain electronic records for the operation and management of their settings. 

Procedures for Electronic Recordkeeping 

Electronic recordkeeping is permissible if all of the following conditions are met: 

1. The electronic record is immediately accessible to, and the medium used to produce the electronic records is able to produce paper copies of records for, OMHSAS or any other oversight provider.
2. The electronic format conforms to the requirements of applicable Federal and State laws.
3. The medium used maintains a record of any deletion, change and that shows the original and altered versions, dates of creation and the creator. 
4. If an provider provides multiple levels of care, the records for each level of care should be maintained separately in the electronic file. 

Use of Electronic Signatures 

Electronic signatures and electronic pad signatures may be used in lieu of pen-and-ink signatures on any document required by regulation to be signed by the facility, the individual receiving services from the setting, or any other individual who may or must sign the document. The use of a PIN is not prohibited. 

As a reminder, a process for electronic signatures needs to be in place. Records should be locked and protected with only authorized personnel permitted access. The record needs to be confidential, therefore, security measures must be in place so that information is only available to staff who are authorized via proper passwords, PINs; etc. 

Shared Space/Co-Location Attestation

Currently, when a provider submits an application to enroll in the MA Provider, and the provider is attempting to enroll with the same distinct address as another currently-enrolled provider, the Department’s Provider Enrollment system identifies the address match and the providers are asked to submit additional information and documentation related to the arrangement between the providers, which has delayed the processing of the provider’s enrollment application(s).

In an effort to facilitate the enrollment of providers that are co-located with other providers, the Department has developed the Co-Location Attestation form, that will allow providers to attest to their compliance with State and Federal anti-kickback laws and the MA regulations at §1101.51, including the freedom of choice provision.

When a provider submits an enrollment or revalidation application and is using the same distinct street address as a different currently-enrolled provider, the Department will identify the address match and will forward the attestation form to both the applicant and the currently enrolled provider(s) along with a request for proposed language for signage. This signage advises beneficiaries that they may receive services from any enrolled provider and must be displayed in a prominent place in the provider’s office, such as a waiting room or at the point of check-in.

In addition, a provider that seeks to enroll at a location that is located within another provider’s offices may also request a copy of the attestation form and submit it and proposed language for signage to the Department prior to the Department identifying the co-location arrangement.

The completed attestation form and proposed language for signage must be submitted to the following by both providers that are at the service location:

Email: RA-ProvApp@pa.gov 

Postal mail: DHS Enrollment Unit

PO Box 8045

Harrisburg, PA 17105-8045

Fax: (717) 265-8284

The Department will review the information and proceed with the processing of the application. The Department may, if needed, request additional information or clarification.

Applicable Regulation(s): § 5200.11(a) (relating to organization and structure).

Shared Space/Co-Location Attestation Form

This attestation is to be completed by a provider that seeks to enroll a location that is co-located with another provider enrolled in the Medical Assistance Provider.  A separate attestation must be completed by both of the providers that are providing services at the service location.

On behalf of ________________________________________________ (“Provider”) which will be co-locating with _____________________________________________ which is a _________________________________________________________, located at the following address: _________________________________________________________,

I attest to the following:

Any agreements for the use of space or equipment or for personnel or management services by the providers must meet the requirements in 42 CFR § 1001.952(b),(c), and (d);

The provider shall comply with all other Federal and State laws and regulations prohibiting illegal kickbacks and referrals;

The space used by the providers shall be separated by walls, partitions, or other means sufficient to guarantee privacy to patients;

The provider will take whatever other measures are necessary to ensure and maintain patient confidentiality in accordance with applicable laws and regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (HIPAA);

The provider shall advise patients that they have freedom of choice in selecting providers and that the patients may choose any Medical Assistance enrolled provider;

The provider shall also display signage, approved by the Department of Human Services, displayed in a prominent place, such as a waiting toon or at the point of check-in, stating that patients may choose any enrolled provide to provide services; 

The provider will not make any direct or indirect referral arrangements between practitioners and other providers of medical services or supplies but may recommend the services of another provider or practitioner; 

The provider will not make automatic referrals.

This attestation does not amend, reduce or eliminate any requirements imposed by State and Federal law and regulation relating to, or governing, the individual provider’s participation in the Medical Assistance Provider.

I possess all necessary powers and authority to execute this Written Attestation on behalf of the provider set forth below and in doing so bind the provider.

I understand that any false statements made therein are subject to the penalties contained in 18 Pa. C.S. § 4904, relating to any unsworn falsifications to authorities.

Printed or Typed Name: ___________________________________________________  

Signature: ____________________________________  Date:____________________                        

Provider Entity: _________________________________________________________

Provider Type: __________________________________________________________                                                               

NPI #: ________________________________________________________________                                                                             

Forward to:

Email: RA-ProvApp@pa.gov

-or-

                              Postal mail: DHS Enrollment Unit 

                                             PO Box 8045 

                                         Harrisburg, PA 17105-8045

-or-

Fax: (717)265-8284