Council on What?
COA will visit the agency starting on this day of the week
What is Monday May 19th, 2025
If a COA auditor asks you a question and you can't access the Policy and Procedure Manual for the answer, do this instead of guessing.
What is ask a Supervisor?
When in doubt about anything, consult with a supervisor. Never guess or make something up.
EBP
What is Evidence Based Practice?
An evidence based practice is Medicaid billable. It has been thoroughly researched and proven effective when used properly.
"Evidence based practices to be provided include Cognitive Processing Therapy, Seeking Safety, Cognitive Behavioral Therapy and Acceptance and Commitment Therapy."
This group provides feedback to Liz and the Board on a monthly basis and consists of volunteers from various programs around the agency.
What is the Consumer Advisory Panel?
"They also plan an annual consumer picnic and publish a yearly consumer newsletter, The Navigator. There is also peer representation on the BBH Board of Directors."
BestSelf's Chief Compliance Officer
Who is Jessica Smith
This document can be found on SharePoint, and can answer any question a COA auditor may ask of you
What is the Policy and Procedure Manual
Staff should only be referencing the electronic version of the manual on SharePoint to ensure the most up to date version.
The largest independent accrediting body for organizations that provide high-quality social and behavioral healthcare services to children, youth, seniors, and families in the United States and Canada.
What is COA?
Council On Accreditation
Pronounced: See-Oh-Ay or Co-Ah
CCBHC
What is Certified Community Behavioral Health Clinic?
"All CCBHC sites offer a full continuum of behavioral health treatment and rehabilitation services. The services operate under the Integrated Outpatient Services license issued by the New York State Office of Mental Health, and provide full treatment and rehabilitation services for individuals with both mental health and substance use disorders."
This group approves the Policy and Procedure Manual
What is The Board? (The Board of Directors)
When an emergency occurs in an office setting, staff can push their panic buttons or do this.
What is call the front staff and ask for the Blue Folder?
Desk drawers, computers and offices containing protected health information should always be secured in your absence to be in compliance with this Act:
What is HIPAA
Maintaining HIPAA compliance is key to a successful COA audit and must be followed at all times
Find the Policy and Procedure Manual here. Anywhere else and you risk using a version that is not up to date.
What is SharePoint
Printed copies are very lengthy and are not guaranteed to be up to date for every program. Please do not print out the manual.
PQI
What is Performance Quality Improvement?
"PQI involves broad stakeholder participation in the ongoing review of quality indicators of programs, as well as administrative processes that support a platform on which quality services can be delivered."
This plan lays out all the staff at BestSelf and who they report to.
What is the organizational chart?
This document advises clients of the agency's behavior/support/management philosophy.
What are the Consumer Rights and Responsibilities
The Consumer Rights and Responsibilities are included in the clinic ROI
Information from this document will be clarified and confirmed during a site visit. (This can be found in the Performance and Quality Improvement reports.)
What is Self Study Evidence?
Self Study Evidence must be submitted 8 weeks before a site visit. This helps provide a broad understanding of an agency that informs how a site visit will be conducted.
If your supervisor isn't available to answer a question about a policy and procedure or to answer other questions, ask this person. Not Liz.
Who is their supervisor's supervisor?
Follow the chain of command for any questions related to policy and procedure. Be aware of organizational leadership to know who to direct questions to.
PDSA
What is Plan Do Study Act?
"PDSA follows the steps of the scientific method and is vital to the implementation of quality improvement at BBH"
This group goes by a three letter acronym and includes all the roles of Vice President and Higher
What is the Senior Leadership Team (SLT)
Client information was accidentally mailed to the wrong person, this is what you do.
What is inform my supervisor and complete a potential HIPAA incident form
potential HIPAA incident forms can be found on SharePoint under - Compliance - reporting forms
This is the location of the Policy and Procedure Manual on Sharepoint
What is the Resouce Center
Contact Software Support and request a record to become this if you happen to come across information related to someone you know on a personal basis. Don't panic and pretend it didn't happen.
What is "sequestered"?
"If any BBH staff should become aware of a consumer that they know on a personal basis, they should immediately request that the record be “sequestered” from them. This means that they will not have any access to that record in our computer software system."
HIPAA
What is the Health Insurance Portability and Accountability Act (HIPAA)
This person leads our board of directors
Who is Ellen Bieler?
Ellen Bieler is the Chair of the Board of Directors.
Three ways a client can notify Bestself of concerns or grievances
What is: