1. Admission Documentation

☑️ Referral/Intake Form – referral source, reason for admission, eligibility (meets ASAM 3.1 criteria).
☑️ Consent Forms – signed ROI, HIPAA acknowledgment, grievance procedure, client rights & responsibilities.
☑️ Comprehensive Biopsychosocial Assessment – completed at admission.
☑️ ASAM Assessment/Level of Care Determination – showing individual meets 3.1 criteria (capable of self-care but not ready for independent living).
☑️ Initial Nursing/Medical Screen – allergies, meds, health concerns, TB test or equivalent.
☑️ Recovery/Wellness Screening – relapse history, community readiness, social supports.

☑️ Initial Treatment/Recovery Plan – completed within 5 working days of admission.

• Signed by client and counselor.

• Includes measurable goals, objectives, interventions, responsible staff, and timelines.
  ☑️ Updates – at least every 30 days (or sooner if clinically indicated).
  ☑️ Collaboration – documented evidence of coordination with therapist, probation, court, or community providers if applicable.
  ☑️ Discharge/Aftercare Plan Initiated at Admission – must begin at entry and updated throughout stay.

☑️ Progress Notes –

• Individual Sessions: at least weekly or biweekly, depending on plan.

• Group Sessions: ≥5 hrs/week structured services (skills training, relapse prevention, recoverysupport).

• Family Sessions: as clinically indicated.

• Notes must include: date, time, duration, service type, content, client response, and signature/credentials of staff.
  ☑️ Attendance Logs – daily sign-in sheets for groups/activities.
  ☑️ Case Management Notes – documentation of linkages to housing, employment, legal, medical, etc.
  ☑️ Crisis/Incident Reports – filed per policy; includes staff response, resolution, and follow-up.

☑️ Medication List / MAR (Medication Administration Record) – if meds are dispensed or monitored.
☑️ Medication Consents – client signature for each psychotropic/substance-use medication.
☑️ Nursing Notes (if applicable) – vitals, side effect monitoring.
☑️ Over-the-counter & PRN logs – documented per state requirements.

☑️ Staffing Records –

• Clinical Director identified.

• Ratios appropriate for census.

• Staff credentials/certifications current.
  ☑️ Supervision Logs – clinical supervision documented regularly.
  ☑️ Training Records – staff trained in ethics, crisis intervention, MHFA, sexual abuse prevention (per COMAR 10.01.18).
  ☑️ Fire/Safety Logs – drills, inspections.
  ☑️ Resident Roster – current census matches Medicaid claims.

☑️ Discharge Summary – reason for discharge, services received, progress toward goals, aftercare referrals.
☑️ Aftercare/Transition Plan – signed by client, includes housing, outpatient care, PRP/OMHC referrals, relapse prevention plan.
☑️ Follow-up Contact – outreach within 30 days (if program policy requires).

• Missing or late initial assessments (must be same-day or admission-day).

• Treatment plans unsigned by client/counselor.

• No updates every 30 days.

• Progress notes that only restate activity instead of skill-building & client response.

• Services billed but no attendance logs.

• Staff credentials not matching service delivered.

• No evidence of collaboration (e.g., with referring clinician, court, probation, OMHC).

• Discharge plans missing or completed after discharge date.

Clinical Director:

• Oversee compliance with ASAM 3.1.

• Ensure staff deliver ≥5 hrs/week structured recovery services.

• Documentation: Admission assessments, treatment plan approvals, staff supervision records.

Counselors / Peer Specialists:

• Deliver relapse prevention, recovery skills, reintegration programming.

• Documentation: Group notes, individual progress notes, skill-building documentation.

Case Managers:

• Coordinate discharge planning, community reintegration.

• Documentation: Housing/employment referrals, aftercare planning notes.