A former off-Broadway actor now cleans ABA clinics for multi-site operators, and argues failures in the physical environment create friction for clinical staff.
Key Takeaways
- The visibility gap: An owner with two clinics can walk in, see a problem, and fix it the same afternoon. Rami Paulus argues that as an organization adds locations, that line of sight naturally becomes harder to maintain, and every clinic manager can begin to apply a private definition of clean enough.
- Two failure modes: Providers either assign cleaning to technicians in-house or hire a vendor built for office buildings and then have staff quietly covering the gaps. Both routes push facilities work onto clinicians who were hired to do something else.
- The evidence is indirect: No published metric ties clinic cleanliness to technician turnover, and Paulus concedes the effect is difficult to measure. Median annual Registered Behavior Technician turnover already runs near 65 percent, and difficult working conditions is one of four themes researchers have identified in RBT burnout.
- What operators can ask now: The practical test is who cleans, who covers when the cleaning does not happen, and whether anyone tracks either answer. That question costs nothing to ask and does not require hiring a vendor to answer.
Somewhere in an ABA clinic today, a Registered Behavior Technician is in a bathroom with a child who needs her full attention, and the roll is empty. Rami Paulus likes to walk operators through what happens next. “Imagine you’re working with a kid, and you’re in the bathroom,” he said over lunch during the ABA C.A.R.E.S. Summit in Boston, which he has now attended three years running. “The kid’s sitting on the toilet, demanding your full attention. And you look to your left to get some toilet paper, and there’s none.” She cannot leave, so she yells down the hallway, and three people are dysregulated over “something that should have been accounted for the night before, that was cheap, almost free to account for.”
Paulus provides janitorial services to multi-site ABA providers through We Clean ABA, which he created in 2024 as a business dedicated to the specialty. He founded his original janitorial company in 2016.
He does not call the product cleaning. “I don’t really see what we do as cleaning first and foremost,” he said. “I see it as environmental infrastructure.” There is clinical infrastructure, meaning the tools and technology a team uses to deliver therapy, and then there is everything that keeps the room itself from becoming a variable.
The Visibility Gap Between Two Clinics and Twenty
His thesis concerns the moment scale outruns supervision. An owner running one or two centers does not need him, he said, because leadership still has visibility and direct control. “Now multiply that times 15 or 30 clinics,” he said. “You walk into every clinic, and every one of them looks and feels different. Each clinical manager is running it with their own subjective point of view.” What follows, in his telling, is not filth so much as drift: “So there’s no real standard across clinics. It’s confusion. It injures parent confidence and fatigues your staff.”
That condition is not hypothetical in a field that consolidated at speed: the ten largest providers account for roughly 1,196 locations between them, per Acuity’s ranking of the sector’s largest platforms, and sponsor-backed platforms took roughly 65 percent of pediatric therapy transactions in the first half of 2026. Franchise operators have built quality audits and owner-operator rules to hold standards steady across sites. In Paulus’s account, that visibility gets harder to hold as locations multiply, and standardized systems become the substitute for it.
From Off-Broadway to Janitorial
He arrived from an unlikely direction. Paulus played drums in punk bands as a teenager and spent his early twenties studying theater and performing off-Broadway in New York and Los Angeles, as he told Voyage Michigan in 2022. His father, who ran a family pipeline construction business in Nigeria, died years before Paulus went into business, and the lessons landed only afterward. Marriage rearranged the rest: he moved back to Detroit, and, after nine years in the arts, set out to build a business. He looked at roughly thirty industries, and chose commercial cleaning, a trade he believed had significant room for improvement in service, reliability, and customer experience.
His first two years cleaning indoor sports complexes taught him what kind of partner he wanted. He moved into healthcare in 2018, picked up an ABA client almost by accident, and stayed. “My feet are firmly planted in ABA,” he said, describing a deliberate choice to narrow rather than expand.
Why ABA Clinics Break a Generic Janitorial Contract
Asked what separates his company from any other vendor, Paulus redirected to the setting. An ABA clinic operates differently from a traditional office or medical space. Children and staff share the same rooms throughout the day, therapy happens on the floor, illness can quickly affect attendance and staffing, and the entire environment has to reset each night to support the next day of care. “Kids eat off the floor when they’re not being watched,” he said, and parents know it. “So when their parents bring them and see that the floor is covered in stains, they’re inferring other things about the clinic.”
Melissa Rigby, a Board Certified Behavior Analyst who co-founded Gateway ABA Therapy in Wareham, Massachusetts in 2020 and runs it, came to the field from early childhood development. She described the same conditions from the operator’s chair. “You’re working with kids who are putting things in their mouth all the time,” she said, along with behaviors that, in her words, nobody wants to talk about but that happen. A medical office resets one room between visits. “When we’re in clinics, kids are sharing space all the time. Staff is sharing space all the time.” Skip the precautions, she added, “and you’re going to see increase in cancelations because everybody’s sick.” Rigby is not a customer.
The standards picture is unsettled. The Centers for Disease Control and Prevention publishes cleaning and disinfecting guidance written for early care and education settings, and states including Massachusetts set sanitation rules for licensed child care programs. Center-based ABA serves that same population inside what is billed as outpatient healthcare, leaving environmental practice to be inferred rather than prescribed.
Two Ways Cleaning Turns Into Additional Work for ABA Staff
Paulus identifies two patterns and considers the second corrosive. The first: providers who assign cleaning to their own technicians, who accepted that when they took the job but hear how the company down the street handles it. The second is subtler: “It’s when they do have an outsourced janitorial company, but the staff are routinely going behind, picking up, and providing coverage for the janitorial company because the janitorial company was never designed to serve ABA with its unique attributes and constraints.” The provider pays for the service and absorbs the labor anyway.
Rigby put the consequence in operational terms. “You’re going to see a higher rate of turnover because people can’t operate in the environment that they’re in,” she said, and when the day goes there, “you can’t even get to your clinical outcomes because everybody’s just trying to regulate in the environment.” Delegating it took closer attention than she expected. “Delegating cleanliness was never something that I thought I’d have to analyze at such a micro level,” she said. Environment is one input among many, and technicians have organized over the bigger ones: RBTs in Rockville, Maryland struck in July over a first contract.
The supporting data is circumstantial, and Paulus does not pretend otherwise. Acuity has previously reported that median annual RBT turnover runs around 65 percent, approaching or exceeding 100 percent at the largest organizations. Researchers interviewing Florida technicians for Behavior Analysis in Practice put difficult working conditions on their short list of reasons people quit, alongside competency, career path, and pay. Neither source isolates facilities as a variable. “It’s hard to measure how that contributes to turnover,” Paulus said, “but it’s obvious that it will.”
The Onboarding Gate and the Standards Behind It
He also turns away work when the conditions required to do it well are not in place. He described visiting a two-clinic operator whose space he found chaotic, proposing shelving and reorganization before any cleaning began, and being turned down. “That’s not what we do,” he said he told them. “We’re here to remove chaos. You’re imposing chaos on yourself.” For Paulus, the point was not the shelving itself but whether the room could be organized well enough to hold a standard at all.
Onboarding runs through a call, a survey, and a second conversation covering cadence, scope, exclusions, and escalation. Paulus considers that last item the one that matters most in a multi-site organization. Defining who raises an issue, how it is documented, and who owns the fix is what keeps a single clinic’s problem from spreading across the portfolio.
The delivery model, in his description, runs on local operating partners recruited market by market and trained to the We Clean ABA program, working within its standards, quality-control processes, and escalation structure. He said he deliberately favors firms for whom the relationship will be meaningful enough to command their attention rather than one more account in a large book of business.
What the Environmental Infrastructure Claim Can and Cannot Support
Pressed on whether he sells retention, Paulus declined the premise. What he promises is consistency, continuity, and accountability across a portfolio. Reduced friction for clinical staff and greater focus for leadership, he said, are outcomes of a stabilized environment rather than contractual deliverables. The relationship between the two is difficult to isolate: there is no independent study of clinic environment and technician churn, no benchmark, and, as both he and Rigby acknowledged, no obvious way to build one.
The framing may outlast the vendor. Order in the room, in his account, sits upstream of everything a clinic measures. “The environmental infrastructure should support the clinical infrastructure,” he said, and at the end of a long lunch: “Your environment can either be a stabilizing force or another source of stress. If you’ve stabilized your environment, you’re regulating your staff. You’re winning the trust of the parents. Your leaders are able to focus, and growth accelerates.”
