1. Licensure and Legal Standing

• Must hold a valid, current license to operate as a behavioral health treatment provider in the state(s) where services are delivered.

• Must provide proof of compliance with all federal, state, and local regulations, including HIPAA, ADA, and CFR 42 Part 2 (confidentiality).

2. Clinical Leadership Requirements

• Clinical Director must meet all the following:

  • Minimum Master’s degree in a behavioral health field (e.g., counseling, social work, psychology, psychiatry, marriage and family therapy).

  • Minimum 5 years post-licensure clinical experience.

  • Must hold an unrestricted license (e.g., LCSW, LMFT, LPCC, Psychologist, Psychiatrist).

• Assistant Clinical Director (if applicable) must meet minimum licensing and supervisory experience (3+ years).

3. Program Composition Requirements

• Program must provide a minimum of:

  • 9 clinical hours per week of group and individual therapy.

  • Access to individual sessions minimum once weekly.

  • Family engagement component (family sessions, family support groups, or education).

• Group sizes must be no larger than 12 participants per clinician to maintain quality of care.

• Evidence-based practices must be the primary modality (minimum 70% of treatment hours), including but not limited to:

  • Cognitive Behavioral Therapy (CBT)

  • Dialectical Behavior Therapy (DBT)

  • Motivational Interviewing (MI)

  • Trauma-Informed Care

  • 12-Step Facilitation (optional but encouraged for SUD-focused programs)

4. Staffing Standards

• Minimum 80% of clinical staff must hold independent licensure (LCSW, LMFT, LPCC, PsyD, MD, RN, or equivalent).

• All staff must pass national background checks and annual ethics disclosures.

• Minimum monthly clinical supervision meetings documented for all clinical and non-clinical staff.

• All staff must complete annual continuing education:

  • Minimum 15 hours/year in behavioral health, ethics, trauma-informed care, or co-occurring disorders.

5. Outcome and Performance Measurement

• Must demonstrate active measurement of patient outcomes using validated tools (e.g., PHQ-9, GAD-7, ASAM Criteria, BASIS-24).

• Must track patient retention, completion, and relapse rates.

• Must demonstrate a written Quality Improvement (QI) Plan updated annually with measurable objectives.

• Minimum outcome benchmark:

  • 70% program completion rate.

  • 50% self-reported improvement in quality of life/symptom reduction at discharge.

6. Ethical Conduct and Consumer Protection

• Must have a written Client Rights and Grievances Policy clearly available to all patients and families.

• Must have a written Ethical Marketing Policy, banning:

  • Patient brokering/kickbacks.

  • Misleading advertising.

  • Incentivized admissions practices.

• Must disclose all ownership interests, financial relationships, and any third-party referral partnerships annually.

7. Safety, Emergency, and Risk Management

• Must maintain a written Emergency Operations Plan (fire, medical, suicide/crisis, natural disaster) updated annually.

• Must conduct annual drills and quarterly safety checks on facility premises.

• Must have on-call clinical staff or crisis response protocols available 24/7 for enrolled clients.

• Liability insurance minimum coverage:

  • $2M/$4M aggregate policy for professional liability and facility insurance.

8. Cultural Competency and Inclusivity

• Must show evidence of cultural competency training for all staff annually.

• Program materials must be available in multiple languages (or interpreter services provided).

• Active nondiscrimination policies in intake, treatment, and discharge.

9. Peer Review and External Oversight

• Must participate in a peer review once every two years (external licensed professional review of charts, outcomes, staff performance).

• Must submit anonymized quarterly reports to BHSO for outcomes tracking (basic metrics, no PHI).

• Subject to random audits by BHSO at any time during accreditation term.

10. Site Inspection and Interview

• Pass on-site inspection evaluating:

  • Clinical records

  • Facility safety

  • Staff interviews

  • Treatment group observation (optional, client permission obtained)

• Executive team and Clinical Director must complete BHSO Accreditation Interview regarding:

  • Treatment philosophy

  • Staff oversight

  • Ethical compliance

  • Strategic growth and improvement plans