1. Licensure and Compliance

• Must hold a valid, current state license as a Partial Hospitalization Program.

• Must comply fully with:

  • HIPAA (Privacy/Security Rules)

  • ADA (Americans with Disabilities Act)

  • OSHA standards (workplace and client safety)

• Must demonstrate credentialing or accreditation by an external body (e.g., Joint Commission, CARF) as a baseline.

2. Medical Oversight

• Must have a designated Medical Director (licensed MD/DO or Psychiatrist).

• Physician must:

  • Conduct an initial face-to-face assessment within 72 hours of admission.

  • Remain accessible for clinical escalation 5 days a week minimum.

• RN or higher credentialed nurse onsite daily during clinical hours.

3. Clinical Services and Programming

• Minimum of 25 hours per week of structured clinical programming, including:

  • Group therapy

  • Individual therapy

  • Family therapy or education

  • Psychoeducation groups (mental health, SUD, trauma, relapse prevention)

• Psychiatric services must be available weekly for medication management if medications are prescribed.

4. Staffing Standards

• Clinical team must include:

  • Licensed therapists (LCSW, LMFT, LPCC, PsyD, etc.).

  • Medical personnel (RN or higher).

  • Psychiatric provider (MD/DO/NP/PA) for medication support.

• Staff-to-client group therapy ratio must not exceed 1:12.

• Weekly clinical supervision meetings required.

5. Admissions and Discharge Planning

• Must complete a comprehensive biopsychosocial assessment within 72 hours of intake.

• Written individualized treatment plan must be developed within 5 days of admission.

• Discharge planning must begin at admission and documented throughout the treatment episode.

6. Outcomes and Quality Improvement

• Track:

  • Admission-to-completion rates.

  • Clinical outcome improvements (PHQ-9, GAD-7, BASIS-24, etc.).

  • 30-day readmission rates.

• Maintain a written Quality Improvement Plan reviewed annually.

7. Ethics and Client Rights

• Must post:

  • Client Bill of Rights.

  • Grievance Procedure visibly.

• Must enforce:

  • No kickbacks, patient brokering, or financial enticements for referrals.

• Full informed consent at admission, including:

  • Treatment risks

  • Financial agreements

  • Privacy rights

8. Safety and Risk Management

• Maintain:

  • Emergency medical policies (911 protocol, seclusion/restraint ban unless licensed to use).

  • Active shooter preparedness training annually.

• Staff must complete:

  • CPR, AED, suicide prevention/intervention training annually.

9. Facility Standards

• Physical environment must include:

  • Secure private offices for therapy.

  • Clean group rooms.

  • Adequate restrooms, emergency exits, ADA access.

10. Oversight and Renewal

• Submit quarterly anonymized outcome reports to BHSO.

• Subject to random inspections by BHSO accreditation auditors.

• Annual renewal process with chart review, facility walkthrough, and leadership interview.