الدخول من خلال النفاذ الوطني الموحد
PR.1. The autism services program (ASP) complies CBAHI pre-accreditation requirements.
PR.1.1. The hosting facility is accredited by CBAHI which is valid for at least 6 months at the time of the certification survey.
PR.1.2. The autism services have submitted a successful interim assessment report within the preceding year of certification survey.
PR.1.3. The hospital/Ambulatory complies with CBAHI's rules and regulations for accreditation maintenance.
PR.1.4. ASP seeking CBAHI certification shall meet all licensing requirements to provide autism service and are valid, as indicated by the statutes and regulations of the Ministry of Health and other relevant national regulatory authorities.
PR.1.5. ASP seeking CBAHI certification must submit a complete application form.
PR.1.6. No refusal policy to accept autism patients.
PR.1.7. ASP is complying with national data registries.
PR.1.8. ASP is actively providing service in the year preceding the certification survey with at least 100 patients served.
PR.2. The ASP has essential settings /space to manage autism patients.
PR.2.1. The services have medical clinic.
PR.2.2. The ASP has dedicated psychological unit/clinic/ services.
PR.2.3. The ASP has dedicated Speech and language pathology unit/ services.
PR.2.4. The ASP has dedicated occupational unit/service.
PR.2.5. The ASP has dedicated Sensory therapy's room that meets the Part I (safe environment) & Part III (Physical Space and Equipment) in the Ayres Sensory Integration Fidelity Measures (ASIFM).
PR.2.6. The ASP has dedicated family counselling Clinic/ service and providing parent counselling services to 100% parents.
PR.2.7. The ASP has dedicated patient's family education units/services.
PR.2.8.
Each clinical room should be equipped with appropriate furniture for the patients and professionals.
PR.2.9. All units are well equipped to deliver proper care for patients.
PM.1. The ASP has approved yearly workforce plan that meet scope of services requirements
PM.1.1. Workforce competencies meet job requirements to deliver services.
PM.1.2. Staff credentials and training are verified and privileging system in place for all clinical staff.
PM.1.3. Staff wellbeing, satisfaction and complains are systematically addressed.
PM.1.4. Staff continuous appraisal system is effective and linked to scope of services and staff productivity.
PM.1.5. All staff receive professional development program that is based on competency check and scope of care.
PM.2. Quality and quantity of staff is suitable to scope of services.
PM.2.1. ABA certificates for professional practicing ABA and other standard therapies are current.
PM.2.2. Certificate for professionals conducting ADOS and other assessment instruments are current.
PM.2.3. Minimum of 1 full time consultants pediatrics (general, neurology, developmental) or child psychiatry.
PM.2.4. At least 1 senior clinical psychology specialist.
PM.2.5. At least 1 senior speech and language pathologist who hold a graduate degree in speech language pathology or a recognized equivalent by the ministry of education and who is licensed by the Saudi Commission of Health Specialties.
PM.2.6. The presence of behavior analyst supervisors, who received a graduate degree or higher in Applied Behavior Analysis or are certified by the Behavior Analyst Certification Board, or hold a license in ABA from an accredited country, is mandatory for the ABA and EI units.
PM.2.7. At least 1 senior occupational therapist who holds a graduate degree in occupational therapy or a recognized equivalent by the ministry of education and who is licensed by the Saudi Commission of Health Specialties; and holds an Ayres Sensory integration certification course that's recognized by the International Council Education of Ayres Sensory Integration.
PM.3. The ASP is managed efficiently and effectively to deliver services to target population.
PM.3.1. The ASP management structure, scope of services, strategic goals and workforce plan are approved by highest authority.
PM.3.2. The hosting organization includes the ASP in strategic plans and insure aliment of its goals and initiatives.
PM.3.3. A competent qualified program director, effectively manages the ASP.
PM.3.4. The ASP director ensures availability of qualified and competent staff at all levels for the delivery of reliable timely and safe care.
PM.3.5. The ASP has and executive/steering committee that meets at least monthly and as needed to ensure the provision of reliable, timely and safe service.
PM.3.6. The ASP optimizes patients flow throughout the hospital from the time they enter until they leave.
PM.4. The ASP enhances social and community participation in autism healthcare services.
PM.4.1. Community representatives participate in ASP strategic planning.
PM.4.2. The ASP provides community with information on its services and its accessibility.
PM.4.3. The ASP enhances ongoing community education to improve the public awareness of the risk factors and symptoms of autism.
PM.4.4. The ASP develops an effective policy and procedure to guide the management of patients and families /service users' complaints, concerns, suggestions, and complements.
PM.4.5. The ASP seeks feedback from patients and service users regarding the services provided.
PM.5. The ASP develop and implement a comprehensive specialized quality and patient safety program.
PM.5.1. ASP has dedicated qualified staff to support the quality of provided services, and align them with hospital quality program.
PM.5.2. Multidisciplinary quality and risk management committee oversees the quality of service.
PM.5.3. The ASP quality team designs and monitors the implementation of risk management program, in line with the hospital risk management program.
PM.5.4. The ASP manages safety incidents, adverse events and near misses that affect or may affect patients/service users, staff, and facility and in line with hospital policy and procedures.
PM.5.5. The ASP prioritizes and selects a set of indicators that focus on the essential structures, processes and outcomes of the services provided.
PM.5.6. The ASP conducts review of the staff performance to ensure adherence to procedural guidelines and provide evidence of the routinely checkups.
PM.5.7. Quality improvement reports are shared with all stakeholders.
PM.5.8. The ASP implement all hospital CPPs, APPs and IPPs.
PM.6. The ASP research activities follow the hospital policies and procedures.
PM.6.1. The hospital research committee or similar structure oversees all research activities.
PM.6.2. Staff are trained on best practices for research regularly.
PM.6.3. The ASP actively participates in national and international autism data registries.
PM.7. The ASP assigned space is safe, adequate, and meet all functions as per scope of services.
PM.7.1. The ASP space is child friendly, least distractive and achieves people with autism safety requirements.
PM.7.2. The ASP space is compliant with all related government legislations and requirements.
PM.7.3. The ASP space shall be suitable for the assessment and therapy of all specialties including, case management, family counselling, multidisciplinary assessment room, and sensory integration room that meets Ayres Sensory Integration (ASI) Fidelity measures.
PM.7.4. Policy to manage access points is in place, and all access points are always monitored.
PM.7.5. Car drop areas, external parking and traffic are safely managed in coordination with related departments.
PM.7.6. Equipment, tools and toys handling and cleaning is done based on infection control policies or guidelines.
PC.1. ASP has approved scope of services to deliver care for targeted population.
PC.1.1. The ASP provide a minimum of medical, psychology, speech therapy, occupational therapy, and behavioral therapy services.
PC.1.2. The ASP has enough staff, safe space, tools, and equipment to perform all its functions.
PC.1.3. The ASP has medical diagnostic facilities directedly or by contracting.
PC.1.4. The ASP do all psychometric tools necessary for assessments.
PC.1.5. The ASP has a parent mediated intervention service.
PC.1.6. The ASP has health promotion as an active component of its functions.
PC.1.7. The ASP ensures that the services available are relevant for its targeted population.
PC.2. The ASP services are accessible to all target populations and as per scope of services.
PC.2.1. The ASP informs patients/parents/guardians about how to access care, treatment, and services, including after hours or in an emergency.
PC.2.2. The ASP has an inclusion criterion for target population according to the approved scope of services.
PC.2.3. The ASP provides care to patients in a planned and timely manner.
PC.2.4. The level of care provided to patients is consistent throughout the ASP. ASP.
PC.2.5. A plan of care is developed and provided to all patients registered as per their condition.
PC.2.6. The system determines the timeframes mandated for patients first encounter in the program.
PC.2.7. The program identifies the essential criteria required for continuity of care.
PC.2.8. The system defines the full-time communication channels to ease urgent patients' referrals.
PC.2.9. The system identifies responsibilities of all staff for acceptance and discharge of patients.
PC.2.10. The system defines the level and content of communication required for patient's acceptance and exit for the program services.
PC.3. All patients receive comprehensive coordinated autism services in a friendly environment.
PC.3.1. A standardized process is in place for registering patients for services based on at least two identifiers, full name as in identification document and ID.
PC.3.2. The program screens patients initially, to direct them to the appropriate service.
PC.3.3. Waiting spaces are well comfortable, ventilated, clean, safe and privacy respected.
PC.3.4. Appointment system is in place to book patients in advance and staff are aware of the services provided.
PC.3.5. Patients are registered under the care of a most responsible physician.
PC.3.6. Parents / guardians are provided with means to contact their healthcare providers including their names and title.
PC.3.7. The program develops a process to minimize language barriers by communicating with patients and family in their primary language.
PC.4. The ASP provides effective Identification process.
PC.4.1. The autism services program develops a process to ensure the correct identification of patients and guardians.
PC.4.2. Patients and guardians are identified by at least two identifiers, full name as in identification document and unique medical record number.
PC.4.3. Patients and guardians are identified before starting any treatment or procedure, and patient handling after therapeutic sessions.
PC.4.4. Patients and guardians are actively involved in the process of patient identification.
PC.4.5. The program monitors the process of patient's identification regularly.
PC.5. The autism service is led by a qualifies consultant physician
PC.5.1. The most responsible physician (MRP) manages and coordinates overall patient care.
PC.5.2. The MRP participates in and oversees the implementation of the principal care plan.
PC.5.3. The MRP agrees to the additional plans developed by other healthcare providers and ensures their implementation.
PC.5.4. The MRP carries the overall responsibility and accountability for the outcome of provided patient care.
PC.5.5. The MRP calls for case conferences as needed to discuss patients' care and concern of therapists and families.
PC.5.6. The MRP carries the overall responsibility and accountability for the transfer of patient responsibility from one physician to another which is guided by a policy and is documented in the patient's medical record.
PC.6. The ASP establishes comprehensive screening, diagnostic, assessment, and reassessment process.
PC.6.1. The program develops autism screening services that are regulated by policy and procedure to include all target populations.
PC.6.2. The policy defines the scope and content of the screening process for all disciplines.
PC.6.3. Patients are referred to the program specialist for further assessment if screening identifies the need for an advanced assessment.
PC.6.4. The screening program uses standardized, scientifically accepted, and age-appropriate screening tools.
PC.6.5. The screening program data are published and shared with all stakeholders.
PC.6.6. The program establishes policy and procedure for the assessment and reassessment of patients that is based on multidisciplinary teamwork.
PC.6.7. The policy and procedure define the assessment and reassessment process for all disciplines and in all autism care settings.
PC.6.8. The parents or guardian actively participates in assessment and reassessment.
PC.6.9. The assessment and reassessment are performed by a multidisciplinary team, which includes a physician, psychologist, Speech Language Pathologist, occupational therapist, and other health care providers as needed."
PC.6.10. The assessment identifies the patient's discharge or referral planning based on the patient's identified ongoing needs and intended therapeutic outcomes.
PC.6.11. The assessment and reassessment of patients is performed through standardized, appropriate, and safe assessment tools/tests.
PC.6.12. The policy defines the time frame for initial assessment completion and the reassessment schedules.
PC.6.13 The multidisciplinary team assessment and reassessment follows the diagnostic process based on best practice.
PC.7. A comprehensive medical assessment is done by a qualified physician.
PC.7.1. The medical assessment includes detailed history, physical and mental examination, and developmental gap.
PC.7.2. All patients go through audiology assessment.
PC.7.3. The assessment includes referral to laboratory, radiology, and other services as per clinical indication.
PC.7.4. The assessment includes the patient's social, economic status and cultural/spiritual needs.
PC.7.5. The assessment ends with a detailed report which includes initial diagnosis, severity level, comorbidity, psychometric result, therapy recommendations and functional goals, and follow-up plan.
PC.7.6. The final diagnosis is documented on chart not later than three months of the initial assessment.
PC.7.7. Patients below two years with undetermined diagnosis are referred to multidisciplinary early intervention services and reevaluated within six months to one year for diagnostic clarification.
PC.7.8. Assessment is done for special cases like the blind, active medical condition, and risk of neglect or abuse.
PC.7.9 Assessment protocol follows an approved guidelines base on international standards and best practices
PC.8. The assessment includes identifying the patient's/ family's educational needs, barriers, and readiness for learning.
PC.8.1. The assessment includes patients and family educational needs.
PC.8.2. The assessment includes patients/family willingness to learn, and learning barriers.
PC.8.3. Healthcare staff utilizes assessment findings for planning the required education.
PC.8.4. The service provides family counseling sessions after completion of the diagnosis process.
PC.8.5. Family support needs from other government agencies is assessed.
PC.8.6. Family agreement to the parent mediated intervention and patient intervention plan is documented.
PC.9. The ASP follow policy and procedure for routine and urgent consultations with other services.
PC.9.1. The consultation question is clearly addressed and consulted service will replay with recommendations that will be addressed in patient care as soon as they arrive.
PC.9.2. The most responsible physician documents the agreement to the recommendations by the consulted services.
PC.9.3. Orders from the consulted services are executed by the managing team only after approval from the patient 's MRP.
PC.9.4. Referral to external services follows policies and procedures and government regulations.
PC.9.5. Referrals to social services support or educational services is as per government regulations and all required documents are filled/attached and patients are educated on how to follow.
PC.9.6. All consultations outcomes are reviewed periodically at least annually.
PC.10. The ASP develops multidisciplinary policy and procedure for the safe prescribing of medications.
PC.10.1. The policy identifies individuals permitted by the relevant laws and regulations to prescribe or order controlled and narcotic medications and their prescribing privileges.
PC.10.2. The ASP oversees and monitor medication management processes.
PC.10.3. The ASP ensures that the physician assesses patient allergy, medication history, appropriate indication of drug, its contraindication, and drug-drug interaction between the prescribed medication and the diagnosis of the case or between different prescribed medications.
PC.10.4. Individuals permitted to prescribe, or order controlled, and narcotic medications are known to pharmaceutical care staff and staff who dispense medications.
PC.10.5. The treating physicians reconcile the patient's medication for any new or refill the prescription.
PC.10.6. The physician evaluates the indication, appropriateness, benefits, risks, and safety considerations for each prescription in accordance with current best practice.
PC.10.7. The physician documents mentoring plans, including required blood tests and physical exams as indicated by current best practice.
PC.10.8. The pharmacist reviews the privilege of prescriber and appropriateness of medication order in term of dose, indication, frequency, dosage form, contraindication and route of administration.
PC.10.9. The pharmacist communicates with the prescribing physician to clarify any concerns regarding the ordered medication, and the clarification is documented before medication dispensing.
PC.10.10. Tele -pharmacy services provided on-site or through a third-party entity have in place a mutual written agreement (LD33/LD34 and to include more specific criteria).
PC.10.11. All prescribed medications are documented in the patient medical record (Hard / local information system).
PC.10.12. The ASP monitors medication prescription process, medication errors, and near-miss events and takes actions accordingly.
PC.11. The services provide and maintain a comprehensive patients' family/ caregiver educational program, in accordance to their needs.
PC.11.1. The program designs an educational structure and allocates resources for an efficient parent education program.
PC.11.2. The parent/family/ caregiver actively participates in patient assessment and intervention sessions.
PC.11.3. The program provides autism parent/ family/caregiver counselling and education at first assessment encounter, with focus on diagnosis, workup and therapy plan.
PC.11.4. The program clarifies specific roles of different staff in patients and parents/family/caregiver education.
PC.11.5. The ASP provides different educational methods and materials to match patients' and parents/family needs and patient 's abilities.
PC.11.6. The ASP provides educational activities in a format and language suitable to patients and families by a specialized educator.
PC.11.7. The program includes patient's flow, financial implications and insurance process.
PC.11.8. The program provides daily activities' book for each patient to be communicated for parent/ family.
PC.11.9. The program provides parent/public education courses at least twice a year.
PC.11.10. The family education program is tailored to a patient 's needs and based on the regular reassessment sessions.
PC.11.11. The program provides full explanation about the intervention, educational plan, and therapy options.
PC.11.12. The program provides family training to apply intervention strategies at home and at different environments.
PC.11.13. The program provides a family support group as needed.
PC.11.14. All parent training and education activities are documented in the patient's medical record.
PC.12. Patients are in a safe facility and are protected at all times.
PC.12.1. The service develops policy to assist and protect patients all times including reporting of abuse and neglect.
PC.12.2. The service has patient and family/caregiver identification and handling policy.
PC.12.3. The service identifies the special needs of all categories of patients.
PC.12.4. The services ensure assistance and protection are obtainable when and where the patient needs them.
PC.12.5. The service has safe building and comply with autism patient's needs.
PC.12.6. The facility is equipped for individual needs including wheelchair access entrance, elevators and disabled toilets.
PC.12.7. The facility is designed for maximum safety and functionality, including proper room size for each function.
PC.12.8. The ASP safety activities and practices are monitored regularly.
PC.12.9. The service has doors locking system with full safety fit with autism requirements.
PC.12.10. The service has assigned qualified security officers enough to assure peoples safety.
PC.12.11. The service provides autism friendly instructions and orientation for patients, families and staff.
PC.12.12. The service provides staff training for security alerts response.
PC.12.13. The service has area specific plan for all external and internal potentials' emergencies and disasters.
PC.12.14. The service has written list of names, titles, and contact numbers of emergencies and disasters responsible staff which include all patients with their parents/relatives contact information.
PC.12.15. The service has designated safety officer.
PC.12.16. the external surrounding of the facility is safe and traffic management plan is in place.
PC.13. The ASP develops a policy and procedure for effective transition plan to ensure the continuity of care.
PC.13.1. Information about the patient's care and response to treatment is shared between medical, nursing, and other care providers.
PC.13.2. When the patient is handed over to the appropriate setting, the ASP ensures the patient is accompanied by a follow-up plan and early warning signs warranting the patients' referral back and information on how to obtain help when required.
PC.13.3. A comprehensive medical report including discharge instructions is sent to the referring institution.
PC.13.4. The transition plan is built at least 3 months before the patient is moved to the other environment.
PC.13.5. The transition plan is goal oriented and based on patients' skills and caregiver needs and preferences.
PC.13.6. The transition plan specifies where and how the patient will have an integration program.
PC.13.7. The caregiver, therapists, and the integrated place shadow teachers participate in the transition plan and provided with proper training.
PC.13.8. The transition plan is documented and a copy is shared with all stakeholders including the patient's caregiver.
PC.14. The ASP team discharges patient through an efficient, safe, and timely process.
PC.14.1. The MRP specifies the estimated date and / or time of discharge for each patient as per-systematic data collection from team members.
PC.14.2. The services have identifiable clinical criteria for discharge and ensures the patient's suitability and stability for discharge.
PC.14.3. Multidisciplinary case conference is in place for every discharge with discussion with patients' parents about discharge indications, process and follow up.
PC.14.4. Follow up plans are arranged to patients and their families prior to discharge and the patient/caregiver are given a copy upon discharge.
PC.14.5. Patients and families have the opportunity to identify and discuss their post- discharge needs.
PC.14.6. All medications and support services necessary for a safe discharge should be organized and documented in the discharge summary.
PC.14.7. A discharge report is documents and handed to patients' parents.
PC.14.8. Discharge criteria from OT services are establish by senior OT in collaboration with team members.
PC.15. All patients go through psychology comprehensive assessment process guided by policy and practice guideline.
PC.15.1. Senior clinical psychologists perform Initial Intake clinical Interview.
PC.15.2. The Initial Intake clinical Interview is comprehensive and detailed and follow well-structured framework.
PC.15.3. Initial intake clinical interview is documented in the patient 's MR
PC.16. A senior clinical psychologist is available to perform a comprehensive psychological assessment.
PC.16.1. Clinical psychologist works closely with a team to evaluate patient 's behaviors and skills.
PC.16.2. Clinical psychologist uses standardized culturally appropriated structured clinical objective assessment tools to assess the number of symptoms and severity level of autism.
PC.16.3. Results of all measures is explained to the caregiver and provided with enough time to review and address their concerns and answer their questions and documented in patients' MR.
PC.17. A senior clinical Psychologists provide Comprehensive behavioral therapy and counseling.
PC.17.1. An age appropriate comprehensive individual pre-intervention objective assessment is done to build an individualized intervention plan.
PC.17.2. An Individual intervention plan and implementation schedules are discussed with families.
PC.17.3. Individual intervention is based on information from assessment measures (norm referenced and criteria reference measures), family report, school concerns if applicable, behavioral observations, and /or transitional needs of individuals
PC.17.4. Therapeutic interventions are structures with specific objectives and planned over a period of time in multiple sessions.
PC.17.5. Therapy should address main concerns raised by caregiver, or difficulties of the patient.
PC.17.6. The in-charge psychologist will contact, consult, or refer to other specialists to get input and for extra care as needed.
PC.17.7. All interventions are documented in patient MR.
PC.17.8. Therapy outcomes are reviewed regularly and conducted every 3 to 6 months.
PC.18. Psychology intervention methods are standardized and evidence based
PC.18.1. Interventions are based on behavioral and educational approaches, and guided by clinical protocols.
PC.18.2. Interventions involve parents as co-therapists to foster social-communicative interaction.
PC.18.3. Preschool patients should have access to maximum hours of appropriate autism specific intervention programs as supported by scientific evidence.
PC.18.4. The intervention plan includes clear autism management strategies for staff, parents, and schools.
PC.18.5. Patients have access to extra or specific individual therapeutic sessions based on needs.
PC.18.6. Patients have access to small group therapeutic educational opportunities based on needs.
PC.18.7. Intervention is based on collaboration with schools and home to ensure consistency of approach across settings.
PC.19. A Group therapy follows care standards and is goal directed.
PC.19.1. Group members are classified based on an approved system, with no more than 8 people in each group.
PC.19.2. Group sessions should be structures, with clear objectives for each session.
PC.19.3. Each session requires providing homework to practice and implement between sessions.
PC.19.4. Intervention therapy is reassessed periodically, and plan modified accordingly.
PC.19.5. Consented agreement is in place explaining rules and expectations.
PC.19.6 Group session activities are documented in details.
PC.20. The ASP conduct effective reassessments for all patients receiving psychology care.
PC.20.1. Patients will have a follow up psychological evaluation every one to two years and as needed.
PC.20.2. Reassessment should include recommendations to update intervention plans to secure more gains.
PC.20.3. All reassessment reports will be shared with other professionals in the patient circle of care.
PC.21. A speech-language and communication service is available and guided by police and practice guideline.
PC.21.1. A senior SLP Specialist conduct assessment services.
PC.21.2. There is an approved SLP service interprofessional practice procedural guidelines that are specific for the center to follow and ensure adherence to best practice guidelines of service provision to patients with autism.
PC.21.3. Documentations of SLPs are reviewed by senior SLP to ensure adherence to procedural guidelines.
PC.21.4. Discharge criteria from SLP service is established by a senior SLP in collaboration with other members of the team.
PC.22. Initial Intake clinical Interview to obtain comprehensive assessment information is performed by senior SLP.
PC.22.1. Formal and informal screening is done to determine the need for further assessment and/or referral for other services.
PC.22.2. Case history and information collection using a standardized form from the patients, caregivers, teachers, and relevant others, including other professionals as required.
PC.22.3. SLP follows a comprehensive evaluation protocol that is culturally and socially appropriate.
PC.22.4. All gathered information is analyzed and interpreted by senior SLP to arrive at a communication disorder diagnosis and make appropriate recommendations for intervention and management.
PC.22.5. Assessment of needs for augmentative and alternative communication is documented and discussed with parents.
PC.22.6. All assessment activities shall recognize the needs, values, preferred mode of communication, and cultural/linguistic background of the individual(s) receiving services, and caregivers.
PC.22.7. All evaluation reports are documented in patient's MR.
PC.23. Intervention plan is developed to meet patients' needs.
PC.23.1. Intervention plan is developed by senior SLP in collaboration with patients, parents, and other caregivers.
PC.23.2. Intervention plan is developed based on the analysis of the assessment data and current evidence that supports the needs of patients with autism.
PC.23.3. Patients' performance and progress is measured and evaluated in regular reassessment activities.
PC.23.4. Intervention plans, strategies, materials, or instrumentation are modified as appropriate to meet the needs of patients.
PC.23.5. Intervention plans recognize the needs, values, preferred mode of communication, and cultural/linguistic background of the individual(s) receiving services and caregivers.
PC.23.6. Comprehensive intervention and reassessment report necessary to support intervention are completed in a timely manner following approved policy (guideline).
PC.24. Speech and language intervention is evidence based and best outcome oriented.
PC.24.1. A policy and procedures and clinical protocol are in place to guide intervention protocols that to have a specific, measurable, attainable, realistic, and measurable outcome goals which are identified and documented.
PC.24.2. Documentation of the performance of the patient on the measurable goal is clearly stated to reflect progress of the patient or the need to modify the goal.
PC.24.3. Outcome goals are updated and modified continuously to upgrade skills and deal with hindering challenges.
PC.24.4. Outcome goals are re-evaluated after no longer than 3 months.
PC.24.5. Identify when it is necessary to refer the patient for other healthcare specialists.
PC.24.6. Discharge criteria is discussed with patient and the caregiver prior to starting therapy.
PC.24.7. Plan for patient discharge is prepared, planed, and documented as early as possible.
PC.24.8. Parent training and involvement is practiced and documented in every session.
PC.24.9. Parents are informed/advised regarding communication and swallowing disorders, with methods that are informative focusing on areas of improvement and future therapeutic needs.
PC.25. Occupational therapy is available and guided by police and practice guideline.
PC.25.1. A senior occupational therapist is available to manage occupational therapy services.
PC.25.2. Junior Occupational therapist may provide assessment services ONLY under the full supervision of a senior Ayres Sensory Integration (ASI) certified occupational therapist who will co-sign any related documents during the assessment services within multidisciplinary team.
PC.25.3. ASI Certified Occupational therapist provide sensory assessment services needed within multidisciplinary diagnostic team or standalone occupational therapy assessment to evaluate self-regulation and sensory needs, adaptive skills, motor development, mental health, social participation, and daily life skills.
PC.25.4. A proof of ASI certification training is needed to assess B4 of DSM-5 within the diagnostic team or to assess sensory processing.
PC.25.5. occupational therapy Interprofessional practice procedural guidelines that are specific for the center seeking accreditation is in place for occupational therapists on the team to follow and ensure adherence to international and national guidelines of service provision to individuals with autism.
PC.25.6. occupational therapy screening protocols are approved and followed.
PC.25.7. A senior occupational therapist conducts review of occupational therapists' documentations to ensure adherence to procedural guidelines and provide evidence of the routinely reviews.
PC.26. All patients go through occupational therapy comprehensive assessment process guided by policy and practice guideline.
PC.26.1. A senior occupational therapist performs Initial Intake Clinical Interview to obtain comprehensive assessment information.
PC.26.2. Screening is conducted to determine the need for further assessment and/or referral for other services.
PC.26.3. Appropriate evaluation procedures are selected to meet the needs of individuals receiving services.
PC.26.4. occupational therapy services are defined according to the patient's & family's needs and desired goals and priorities for participation.
PC.26.5. Occupational therapy process involves evaluation, intervention, and measurement of outcomes.
PC.26.6. Assessment of needs for sensory integration therapy is documented and discussed with parents.
PC.26.7. Evaluation reports necessary to support the occupational performance and intervention plan are completed in a timely manner.
PC.27. Occupational therapy intervention settings are developed to meet patients' needs.
PC.27.1. Intervention plan is developed in collaboration with patients/ caregivers and professionals from other disciplines as needed.
PC.27.2. Intervention plans are implemented with involvement of patients and caregivers.
PC.27.3. Appropriate materials and instrumentation are used for intervention.
PC.27.4. Patients' performance and progress is measured and evaluated in regular reassessment activities.
PC.27.5. Intervention plans, strategies, materials, or instrumentation are modified as appropriate to meet the needs of patients/caregiver.
PC.27.6. Comprehensive intervention and reassessment report necessary to support intervention are completed in a timely manner.
PC.28. Occupational therapy intervention shall be evidence based and best outcome oriented.
PC.28.1. Specific outcome goals based on the Goal Attainment Scaling are identified, drafted, and documented.
PC.28.2. Numbers of occupational therapy sessions should be enough to achieve intended outcome goals.
PC.28.3. Outcome goals are updated and modified continuously to upgrade skills and deal with hindering challenges.
PC.28.4. Whenever necessary attend combined sessions and or refer to other specialists to deal with challenging behaviors.
PC.28.5. Discharge criteria are discussed with parents and documented as early as possible.
PC.28.6. Caregiver training is practiced and documented in every session.
PC.28.7. Caregiver are counseled regarding their patient's functional abilities, with methods that are informative focusing on areas of improvement and future therapeutic needs.
PC.29. Intervention space is sufficient and efficient to deliver intended therapy goals.
PC.29.1. Rooms are suitable for all ages and complexity of conditions.
PC.29.2. Rooms include areas of single therapy sessions.
PC.29.3. A proof of certification training in ASI is required to provide sensory integration intervention as outlined in the ASIFM.
PC.29.4. Therapy rooms' safety measures are outlined and always observed.
PC.30. Applied Behavior Analysis (ABA)/ Early Intervention (EI) services are guided by policy and practice guideline.
PC.30.1. Qualified professionals are available to deliver Applied Behavior Analysis (ABA) and Early Intervention (EI) services.
PC.30.2. ABA and/or EI services are supervised by a senior professional.
PC.30.3. Professionals (e.g., behavior analysts, psychologists, special educators, and EI specialists) working in the EI unit are trained in EI as part of a degree program or post-degree program.
PC.30.4. A clear ABA/EI professional hierarchy is developed and communicated.
PC.30.5. Each therapist should have a specific number of cases. The number of cases is determined based on the number of hours a therapist works, in addition to allocated time (e.g., 15 minutes for each case) to record, graph, and review patients' progress towards their instructional goals.
PC.31. The autism team develops a comprehensive multidisciplinary early intervention plan.
PC.31.1. EI plan is based on formal and informal assessments.
PC.31.2. EI plan is developed through a collaborative approach with other disciplines.
PC.31.3. The plan of care sets desired outcomes that are observed and can be measured based on the assessment results and caregiver's goals for their patient.
PC.31.4. The plan of care should indicate reassessment schedules.
PC.31.5. A progress report that includes the patient 's progress should be provided to the caregiver and kept in the patient 's records within 5 working days.
PC.32. Early intervention is provided as basic function of ASP and is based on evidence base/ best international practices.
PC.32.1. Intensive early intervention programs are available for young patients before the age of 6 years old.
PC.32.2. EI programs should focus on increasing communication skills, verbal behavior, self-management skills, social skills and self-care skills.
PC.32.3. All objectives in EI and ABA units should be based on the direct and indirect assessment results. In addition to the caregiver's desired goals.
PC.32.4. Intervention should include both skill acquisition and behavior reduction goals.
PC.32.5. The number of acquisition and behavior reduction goals coincide with the number of hours the patient is at the ASP.
PC.32.6. Skill acquisition goals are defined into long-term objectives and broken down into short-term objectives.
PC.32.7. All long-term objectives and short-term objectives are defined in measurable and observable way.
PC.32.8. The autism team collect data on correct and incorrect responses of the short-term objectives that are presented to the patient during the intervention sessions
PC.32.9. The behavior analyst supervisor monitors the progress of the patients in the ASP and review decisions made on therapy protocol.
PC.32.10. The behavior analyst supervisor creates a training plan to train everyone in the patient 's team to implement the behavior reduction plan consistently and reliably
PC.32.11. The behavior analyst supervisor set up a schedule to observe everyone continuously in the patient 's team implement the behavior reduction plan and provide feedback.
PC.32.12. The intervention format is a mixture of a 1-to-1 format and group-format based on the patient 's unique needs, and best practice guidelines.
PC.32.13. The services delivery model of the intervention services is center-based, home-based and/or virtually, or in the community.
PC.32.14. The behavioral program delivers outpatient services to integrate patients in the general education system and in the community when applicable with appropriate staff members.
PC.33. Whenever provided play therapy is based on best practice standards.
PC.33.1. Play therapy is performed by a qualified staff.
PC.33.2. A policy in a place to clarify roles and responsibilities of the play therapist.
PC.33.3. The policy clarifies process, list tools, equipment, spaces and safety parameters required to perform play therapy sessions.
PC.33.4. The play therapy sessions are an integral part of interdisciplinary team intervention plans.
PC.33.5. Play therapy is conducted within the patient therapy zone.
PC.33.6. Equipment and toys selection criteria meet patient's safety and play therapy goals.
PC.33.7. All play therapy practices supported by evidence-based guidelines.
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