Compliant Patient Chart Audit Form

Compliance Reminder – Claim Adjustments
All staff completing this audit are responsible for following Medicaid/DSS/DCF compliance standards:

Required Adjustments:

Correct overpaid/underpaid claims.
Correct claims with wrong client ID, NPI, or date of service.
Prohibited Adjustments:

Do not adjust claims under open audit.
Any errors on audited claims must be referred to Compliance for self-disclosure review.
Recoupment & Self-Disclosure:

Overpayments must be reported and repaid per DSS protocol (42 CFR §455.18).
All actions must be logged in the Audit Tool under Root Cause, Immediate Correction, Prevention, Responsible Person, Due Date, Verification, and IT Ticket/Next Progress Note.

Oversight:

The Compliance Officer/Designee reviews adjustments monthly.
The Governing Board is updated quaterly per DCF §17a-20-56.

By completing this audit, you acknowledge these requirements and your responsibility for compliance.

 

Referral source documented (DCF §17a-20-54)

The audit identified that the referral source was not documented at intake, a requirement under DCF §17a-20-54 to establish how the child entered care and substantiate medical necessity.

Root Cause: Intake staff overlooked this field, and Epic did not require its completion.

Immediate Correction: The clinician updated the Referral Source field in the Epic Intake SmartForm and signed the entry on [DATE].

Prevention: Epic will be modified to make the Referral Source field mandatory, and supervisors will review all new admissions weekly.

Responsible Person: Clinical Supervisor ensures correction; CCO oversees Epic build; CEO monitors compliance.

Due Date: Within 3 business days for correction, 14 days for system updates.

Verification: Weekly review of the “New Admissions – Missing Referral Source” report in Epic and random chart re-audits.

Epic Fix: Intake → Intake SmartForm → complete “Referral Source” → Save/Sign.

IT Ticket: “Please make Referral Source a required field in the OPCC Intake SmartForm for patient [MRN] to meet DCF §17a-20-54.”

Next Progress Note: “On [DATE], referral source was documented in Epic and linked to admission encounter.”

Pre-admission/referral data included (DCF §17a-20-54)
The audit revealed missing pre-admission/referral data, required to justify treatment need.

Root Cause: Clinician did not gather or enter the pre-admission details during intake.

Immediate Correction: The Psychosocial Assessment SmartForm was updated with referral rationale and pre-admission details on [DATE].

Prevention: Epic will be configured to require completion of the Pre-Admission section before the SmartForm can be signed.

Responsible Person: Clinical Supervisor monitors, CCO oversees system edits, CEO provides oversight.

Due Date: Within 3 business days for correction, 14 days for workflow updates.

Verification: Supervisor uses Epic “Intake Completeness Dashboard.”

Epic Fix: Intake → Psychosocial Assessment SmartForm → complete “Pre-Admission” fields.

IT Ticket: “Activate/require Pre-Admission fields in Psychosocial/Intake SmartForm for OPCC [MRN].”

Next Progress Note: “On [DATE], pre-admission/referral data were added to the intake record to support medical necessity.”

Informed consent signed by parent/guardian before/at first session (DCF §17a-20-35; 42 CFR §441.170)

Audit found informed consent missing at the time of treatment initiation, a violation of Medicaid and DCF rules.

Root Cause: Services began prior to obtaining guardian consent, and Epic did not block session entry without a consent upload.

Immediate Correction: Guardian signed consent on [DATE]; form was uploaded to Epic → Documents → Consents.

Prevention: Epic will implement a hard stop preventing service entry without an uploaded consent.

Responsible Person: Clinical Supervisor ensures all consents are collected, CCO confirms workflow hard stop, CEO reviews high-risk cases. Due Date: Immediate, no later than next business day.

Verification: Weekly “Missing Consent” Epic report and 100% re-audit of new intakes for 30 days.

Epic Fix: Documents → Consents → upload scanned consent; Intake Note → document review.

IT Ticket: “Enable consent hard stop for OPCC encounters; Consent SmartForm must be completed for patient [MRN] prior to treatment.”

Next Progress Note: “On [DATE], guardian consent obtained and uploaded; rights and responsibilities reviewed with guardian.” Collateral Contact Log: If obtained outside a visit, document guardian confirmation by phone.

Patient rights explained, signed, and documented (DCF §17a-20-35; 42 CFR §438.100)

Audit revealed no documentation of patient rights review, required by regulation.

Root Cause: Clinician failed to review rights with guardian, and Epic template lacked a required rights section.

Immediate Correction: Rights were explained and signed acknowledgment uploaded on [DATE]; clinician added “.rights” SmartPhrase to intake note.

Prevention: Epic will require Rights acknowledgment upload; intake template updated with “.rights” SmartPhrase.

Responsible Person: Clinical Supervisor ensures completion; CCO modifies templates; CEO monitors. Due Date: Within 3 business days.

Verification: Supervisor spot-checks intake packets weekly.

Epic Fix: Intake Note → insert “.rights” SmartPhrase; Documents → upload acknowledgment.

IT Ticket: “Please enable the .rights SmartPhrase and require Rights acknowledgment upload in OPCC intake [MRN].”

Next Progress Note: “On [DATE], rights were reviewed with guardian and acknowledgment uploaded.”

Grievance procedure explained & signed (DCF §17a-20-34; 42 CFR §438.406)

The audit identified no signed grievance acknowledgment, which violates Medicaid grievance rights.

Root Cause: Form omitted from intake packet.

Immediate Correction: Grievance policy reviewed with guardian; signed acknowledgment uploaded on [DATE].

Prevention: Epic will make grievance form upload mandatory for intake completion.

Responsible Person: Clinical Supervisor ensures review; CCO updates workflow; CEO confirms monthly readiness. Due Date: 3 business days.

Verification: Intake packets re-audited; CEO reviews grievance compliance monthly.

Epic Fix: Documents → Grievance Acknowledgment → upload.

IT Ticket: “Require Grievance Acknowledgment upload for OPCC intakes [MRN].” Next

Progress Note: “On [DATE], grievance process explained; acknowledgment uploaded.” Collateral Contact Log: Record guardian confirmation if done remotely.

Confidentiality acknowledgment (CGS §§52-146c–j; 42 CFR Part 2; HIPAA 45 CFR §164.502)

Confidentiality acknowledgment was missing from the chart, a violation of HIPAA/42 CFR Part 2.

Root Cause: Staff oversight; Epic did not enforce acknowledgment.

Immediate Correction: Guardian reviewed confidentiality on [DATE]; signed acknowledgment uploaded.

Prevention: Epic workflow updated with hard stop requiring confidentiality acknowledgment.

Responsible Person: Clinical Supervisor confirms completion; CCO implements Epic hard stop; CEO reviews monthly compliance. Due Date: Immediate, within 1 business day.

Verification: Weekly “Missing HIPAA/Part 2” report in Epic.

Epic Fix: Intake Note → add Confidentiality SmartPhrase; Documents → upload acknowledgment.

IT Ticket: “Add mandatory Confidentiality acknowledgment to OPCC Intake workflow for [MRN].”

Next Progress Note: “On [DATE], confidentiality reviewed with guardian; acknowledgment uploaded.” Collateral Contact Log: Document guardian confirmation if completed outside a session.

Assessment completed at admission (DCF §17a-20-41)

The audit found that the initial assessment was not completed at the time of admission, violating DCF §17a-20-41 requirements.

Root Cause: The clinician did not complete or sign the Psychosocial Assessment SmartForm at intake, and Epic did not generate a mandatory alert.

Immediate Correction: The assessment was completed and signed on [DATE] using the Epic Psychosocial Assessment SmartForm.

Prevention: Epic will issue an “Assessment Due” alert in the Task List and prevent signing without completion.

Responsible Person: Clinical Supervisor ensures clinician compliance, CCO oversees Epic alert, CEO monitors high-risk items.

Due Date: Within 3 business days. Verification: Supervisors review the “Unsigned/Incomplete Assessments” Epic report weekly.

Epic Fix: Assessments → Psychosocial Assessment SmartForm → complete and Sign.

IT Ticket: “Enable Assessment Due at Admission alert and require e-signature for OPCC assessments [MRN].”

Next Progress Note: “On [DATE], initial assessment completed and signed; plan of care initiated.”

Methods, tools, and tests described; scores included (DCF §17a-20-41)

Audit showed that standardized tools (e.g., PHQ-9, Vanderbilt) were used but scores not entered.

Root Cause: Clinician documented narrative but failed to record test scores, and Epic did not require entry.

Immediate Correction: Scores and interpretations were entered into the Assessment SmartForm on [DATE].

Prevention: Epic template updated with mandatory score fields.

Responsible Person: Clinical Supervisor ensures correction; CCO validates SmartForm updates.

Due Date: Within 3 business days. Verification: Supervisor audits 10 assessments monthly.

Epic Fix: Assessment SmartForm → Measures/Tools section → enter scores & interpretation.

IT Ticket: “Add mandatory fields for standardized measure scores in OPCC Assessment SmartForm for [MRN].”

Next Progress Note: “On [DATE], standardized tool scores entered and reviewed with guardian.”

Includes medical, developmental, psychological, family, social, educational, and legal history (DCF §17a-20-41)

Audit revealed incomplete biopsychosocial domains.

Root Cause: Clinician skipped sections due to time constraints and Epic did not lock incomplete assessments.

Immediate Correction: Missing medical, developmental, and family history were completed on [DATE].

Prevention: Epic will lock Assessment SmartForm until all domains are filled.

Responsible Person: Clinical Supervisor checks completeness; CCO configures workflow; CEO monitors. Due Date: 3 business days.

Verification: Supervisor reviews “Assessment Completeness Dashboard.”

Epic Fix: Assessment → complete Medical, Developmental, Family, Social, Educational, Legal sections.

IT Ticket: “Require completion of all biopsychosocial domains before Assessment signature for OPCC [MRN].”

Next Progress Note: “On [DATE], all assessment domains completed to support medical necessity.”

Strengths and weaknesses documented (DCF §17a-20-41; 42 CFR §440.130(d))

Audit identified that only deficits were documented without strengths.

Root Cause: Clinician used a deficit-based narrative and Epic did not require strengths field.

Immediate Correction: Strengths were added to the Assessment on [DATE].

Prevention: Epic template will require completion of “Strengths” and “Needs.”

Responsible Person: Clinical Supervisor ensures strengths-based entries; CCO configures field.

Due Date: 3 business days.

Verification: Supervisor audits 10 charts per quarter.

Epic Fix: Assessment → Strengths/Needs subsection → complete.

IT Ticket: “Add mandatory Strengths field to OPCC Assessment SmartForm for [MRN].”

Next Progress Note: “On [DATE], strengths and barriers documented; plan updated accordingly.”

Family/guardian involvement documented (DCF §17a-20-41(d))

Audit found no evidence of family involvement.

Root Cause: Clinician did not document guardian participation; Epic template did not require collateral entry.

Immediate Correction: A Collateral Contact note documenting guardian input was added on [DATE].

Prevention: Epic workflow will require at least one guardian collateral before finalizing assessment.

Responsible Person: Clinical Supervisor ensures guardian involvement; CCO enforces via Epic; CEO reviews systemic compliance.

Due Date: 3 business days.

Verification: Supervisor audits Collateral Contact logs.

Epic Fix: Notes → Collateral Contact → document guardian input & link to Assessment.

IT Ticket: “Activate/require Collateral Contact note type for OPCC assessments [MRN].”

Next Progress Note: “On [DATE], guardian collateral obtained and integrated into assessment.”

Collateral Contact Log: Document guardian’s input and outcome of the contact.

Mental status exam completed
Audit revealed the MSE section was blank.

Root Cause: Clinician skipped the Mental Status Exam.

Immediate Correction: Completed MSE fields in Assessment SmartForm on [DATE].

Prevention: Epic template will require MSE before signature.

Responsible Person: Clinical Supervisor ensures completion; CCO enforces template edit.

Due Date: 2 business days.

Verification: Supervisor checks “Assessment Completeness Report.”

Epic Fix: Assessment → Mental Status Exam section → complete.

IT Ticket: “Require MSE completion before Assessment signature for OPCC [MRN].”

Next Progress Note: “On [DATE], MSE completed; no acute safety risks identified.”

Psychosocial history included

Audit showed psychosocial history was missing.

Root Cause: Clinician omitted narrative. Immediate Correction: Psychosocial history added on [DATE].

Prevention: Template cue added to Epic requiring psychosocial narrative.

Responsible Person: Clinical Supervisor monitors; CCO updates template.

Due Date: 3 business days.

Verification: Supervisor random chart audits.

Epic Fix: Assessment → Psychosocial History section → complete.

IT Ticket: “Ensure Psychosocial narrative field is present and required in OPCC Assessment [MRN].”

Next Progress Note: “On [DATE], psychosocial history documented; reviewed with guardian.”

Medication history/current status reviewed

Audit found no medication reconciliation.

Root Cause: Clinician skipped medication history; Epic did not enforce reconciliation.

Immediate Correction: Medication reconciliation completed and updated on [DATE].

Prevention: Epic intake workflow to include required med rec prompt.

Responsible Person: Clinical Supervisor ensures med rec at intake; CCO adds system reminder.

Due Date: 2 business days.

Verification: Med Rec completion metric in Epic.

Epic Fix: Meds & Orders → Medication Reconciliation; Assessment → document med history.

IT Ticket: “Enable med reconciliation prompts in OPCC intake workflows for [MRN].”

Next Progress Note: “On [DATE], medications reconciled and reviewed with guardian.”

Labs/diagnostic orders reviewed if indicated

Audit found lab results were not reviewed/documented.

Root Cause: Clinician did not review or summarize labs.

Immediate Correction: Lab and diagnostic results reviewed and summarized in Assessment on [DATE].

Prevention: Epic template to include reminder for labs/diagnostics review.

Responsible Person: Clinical Supervisor monitors; CCO configures reminder.

Due Date: 3 business days.

Verification: Supervisor sign-off during chart reviews.

Epic Fix: Chart Review → Labs/Imaging → summarize in Assessment.

IT Ticket: “Add labs/diagnostics review reminder to OPCC Assessment template for [MRN].”

Next Progress Note: “On [DATE], lab and diagnostic results reviewed and discussed with guardian.”

Initial diagnosis, functional status, formulation documented

Audit revealed diagnosis and case formulation missing.

Root Cause: Clinician left Dx and formulation fields blank.

Immediate Correction: Diagnosis and formulation entered on [DATE].

Prevention: Epic will require Dx and formulation before signature.

Responsible Person: Clinical Supervisor ensures correction; CCO enforces system requirement.

Due Date: 2 business days.

Verification: Diagnosis completeness report.

Epic Fix: Assessment → Diagnosis, Functional Status, Formulation sections → complete.

IT Ticket: “Require Dx and formulation completion prior to OPCC Assessment signature [MRN].”

Next Progress Note: “On [DATE], diagnosis and case formulation documented to guide treatment.”

Signed by evaluating clinician, with credentials (DCF §17a-20-41)

Audit found the assessment unsigned.

Root Cause: Clinician did not electronically sign assessment.

Immediate Correction: Clinician signed the document on [DATE].

Prevention: Epic will block billing for unsigned assessments.

Responsible Person: Clinical Supervisor verifies signature; CCO validates e-signature display.

Due Date: 1 business day.

Verification: “Unsigned Documents” Epic report.

Epic Fix: Assessment → Sign Document → confirm credentials visible.

IT Ticket: “Fix e-signature/credential display in OPCC Assessment for [MRN].”

Next Progress Note: “On [DATE], assessment signed; treatment plan initiated.”

Physician/APRN evaluation documented if medication indicated

Audit found no prescriber evaluation documented despite medication indication.

Root Cause: Task not routed to prescriber.

Immediate Correction: APRN completed evaluation note on [DATE].

Prevention: Epic auto-task APRN/MD whenever “medication indicated” is selected.

Responsible Person: Clinical Supervisor ensures task completion; CCO validates routing rule; CEO ensures credentialing compliance.

Due Date: 3 business days. Verification: Prescriber evaluation task queue monitored weekly.

Epic Fix: Prescriber Note → Medication Evaluation template; link to Assessment.

IT Ticket: “Auto-route prescriber task when ‘medication indicated’ selected for OPCC [MRN].”

Next Progress Note: “On [DATE], APRN evaluation completed; medication plan reviewed with guardian.”

Medical necessity clearly established (42 CFR §440.230)

Audit showed no clear medical necessity statement.

Root Cause: Clinician did not link symptoms and impairments to need for treatment.

Immediate Correction: Added medical necessity narrative on [DATE].

Prevention: Epic template updated with required “Medical Necessity” field.

Responsible Person: Clinical Supervisor ensures quality entries; CCO enforces via Epic.

Due Date: 2 business days. Verification: Supervisor reviews necessity statements monthly.

Epic Fix: Assessment → Medical Necessity field → complete.

IT Ticket: “Add required Medical Necessity field to OPCC Assessment for [MRN].”

Next Progress Note: “On [DATE], medical necessity updated; services remain indicated.”

 

 
 
 
 
 

 

Perfect 👍 — here’s Section C: Initial Treatment Plan with full Corrective Action Plan (CAP) narratives for each checkbox item, in the same format we’ve been building.

📋 Section C: Initial Treatment Plan (Due within 30 days) – CAP Narratives

Diagnosis included (DCF §17a-20-42)

The audit revealed that the initial treatment plan was missing a documented DSM-5/ICD-10 diagnosis, which is required under DCF §17a-20-42 and Medicaid billing rules.

Root Cause: The clinician saved the plan without entering a diagnosis, and Epic did not enforce the field.

Immediate Correction: The diagnosis was entered into the Treatment Plan SmartForm and electronically signed on [DATE].

Prevention: Epic will require completion of the Diagnosis field before plan submission.

Responsible Person: Clinical Supervisor ensures diagnosis is included; CCO implements Epic enforcement; CEO monitors system compliance.

Due Date: Correction within 2 business days.

Verification: Plan completeness report reviewed weekly.

Epic Fix: Treatment Plan SmartForm → Diagnosis → complete and sign.

IT Ticket: “Require diagnosis field in OPCC Treatment Plan SmartForm for [MRN].”

Next Progress Note: “On [DATE], diagnosis entered into treatment plan; billing standards met.”

Type, amount, frequency, and duration of services specified

Audit found that service parameters (type, frequency, duration) were not defined in the treatment plan.

Root Cause: Clinician left the service details blank; Epic allowed plan submission.

Immediate Correction: The fields were completed on [DATE].

Prevention: Epic will enforce completion of service parameter fields and supervisors will spot-check all new plans.

Responsible Person: Clinical Supervisor (review); CCO (Epic validation); CEO (oversight).

Due Date: 2 business days. Verification: Supervisor review of new plans.

Epic Fix: Treatment Plan → Services section → enter type, frequency, duration.

IT Ticket: “Require services fields (type, frequency, duration) in OPCC Treatment Plan [MRN].”

Next Progress Note: “On [DATE], service frequency and duration documented per plan.”

Measurable, time-bounded goals/objectives (DCF §17a-20-42(b); 42 CFR §441.170)

Audit showed goals written vaguely (“improve coping”), which do not meet Medicaid standards.

Root Cause: Clinician failed to use SMART format; Epic template lacked structured prompts.

Immediate Correction: Goals rewritten into measurable objectives on [DATE].

Prevention: Epic will include a SMART Goals SmartText block to guide staff.

Responsible Person: Clinical Supervisor monitors; CCO adds SmartText; CEO ensures compliance.

Due Date: 3 business days.

Verification: Random audits for measurable goals.

Epic Fix: Treatment Plan → Goals → insert SMART Goals SmartText. IT Ticket: “Add SMART Goals SmartText to OPCC Treatment Plan for [MRN].”

Next Progress Note: “On [DATE], goals revised to measurable objectives (e.g., tantrums reduced to ≤2/week in 90 days).”

Specialized services/referrals listed with responsible party (DCF §17a-20-42(d))

Audit found no documentation of referrals or assigned responsibility.

Root Cause: Clinician did not enter referral info; Epic did not require it.

Immediate Correction: Referrals and responsible staff documented on [DATE].

Prevention: Add required Referrals/Responsible Party fields to Epic.

Responsible Person: Clinical Supervisor monitors; CCO ensures build; CEO reviews compliance.

Due Date: 3 business days.

Verification: Supervisor plan review.

Epic Fix: Treatment Plan → Referrals/Responsible fields → complete.

IT Ticket: “Add required Referrals/Responsible Party fields to OPCC Treatment Plan [MRN].”

Next Progress Note: “On [DATE], referrals documented; coordination initiated.”

Functional strengths/limitations identified

Audit showed plan did not include strengths or limitations.

Root Cause: Clinician omitted required content; Epic allowed incomplete plan.

Immediate Correction: Strengths and limitations were documented on [DATE].

Prevention: Epic template will require completion of these fields.

Responsible Person: Clinical Supervisor ensures corrections; CCO enforces template change.

Due Date: 3 business days.

Verification: Supervisor audits 10% of plans quarterly.

Epic Fix: Treatment Plan → Strengths/Limitations → complete.

IT Ticket: “Require Strengths/Limitations completion in OPCC Treatment Plan [MRN].”

Next Progress Note: “On [DATE], strengths and limitations documented in plan; interventions aligned.”

Discharge criteria specified (DCF §17a-20-42(e))

Audit revealed no discharge criteria in the plan.

Root Cause: Clinician left discharge section blank.

Immediate Correction: Discharge criteria were documented on [DATE]. Prevention: Epic will enforce completion of discharge criteria field.

Responsible Person: Clinical Supervisor ensures completion; CCO enforces build; CEO monitors.

Due Date: 2 business days.

Verification: Plan audit monthly. Epic Fix: Treatment Plan → Discharge Criteria → complete.

IT Ticket: “Require discharge criteria field before OPCC Treatment Plan signature [MRN].”

Next Progress Note: “On [DATE], discharge criteria documented and reviewed with guardian.”

Supports/resources for discharge identified

Audit showed aftercare supports/resources not included.

Root Cause: Clinician did not complete aftercare planning.

Immediate Correction: Aftercare supports documented in plan on [DATE].

Prevention: Epic template to include required Aftercare Resources field.

Responsible Person: Clinical Supervisor reviews; CCO builds field.

Due Date: 3 business days.

Verification: Supervisor audit.

Epic Fix: Treatment Plan → Aftercare Supports/Resources.

IT Ticket: “Add Aftercare Supports/Resources field to OPCC Treatment Plan for [MRN].”

Next Progress Note: “On [DATE], aftercare resources planned with guardian.”

Anticipated discharge date included (DCF §17a-20-42(i))

Audit identified no discharge date in the plan.

Root Cause: Clinician omitted entry; Epic allowed completion without a date.

Immediate Correction: Anticipated discharge date entered on [DATE].

Prevention: Epic will require discharge date entry.

Responsible Person: Clinical Supervisor ensures entry; CCO enforces template; CEO ensures compliance.

Due Date: 2 business days.

Verification: Plan completeness dashboard.

Epic Fix: Treatment Plan → Anticipated Discharge Date → enter date.

IT Ticket: “Require Anticipated Discharge Date in OPCC Treatment Plan [MRN].”

Next Progress Note: “On [DATE], anticipated discharge date entered and reviewed with guardian.”

Signed by parent/guardian, child (if capable), clinician, and chief administrator/designee (DCF §17a-20-42(l))

Audit revealed missing signatures.

Root Cause: Clinician finalized plan without obtaining all required signatures.

Immediate Correction: Guardian signature uploaded; clinician, child, and administrator signatures completed on [DATE].

Prevention: Epic will require all signatures before plan finalization.

Responsible Person: Clinical Supervisor confirms signature collection; CEO signs as administrator; CCO enforces routing rules.

Due Date: Immediate, within 3 business days. Verification: “Missing Signatures – Treatment Plans” report.

Epic Fix: Treatment Plan → Route for Signature; Documents → upload scanned guardian signature.

IT Ticket: “Enable signature routing for all required plan signers before finalization of OPCC Treatment Plan [MRN].”

Next Progress Note: “On [DATE], all required treatment plan signatures obtained and uploaded.” Collateral Contact Log: Document guardian confirmation if signature obtained remotely.

Reviewed 90 days after first plan; then every 90 calendar days (DCF §17a-20-43; 42 CFR §441.155)

The audit revealed that a treatment plan review was overdue by 15 days, violating DCF and Medicaid requirements for timely reviews.

Root Cause: The clinician did not complete the 90-day review, and Epic did not issue a reminder alert.

Immediate Correction: The Treatment Plan Review SmartForm was completed on [DATE], signed by the clinician, and routed for guardian review.

Prevention: Epic will be configured to generate an alert in the Task List at day 80, reminding clinicians of the upcoming review. Supervisors will check the “Plan Review Timeliness” dashboard weekly.

Responsible Person: Clinical Supervisor monitors completion; CCO ensures alerts are active; CEO monitors systemic compliance.

Due Date: Immediate, within 2 business days.

Verification: “Plan Reviews Due/Overdue” dashboard reviewed weekly.

Epic Fix: Treatment Plan → Plan Review SmartForm → complete/sign → schedule next review.

IT Ticket: “Please enable automated alerts at day 80 for treatment plan reviews in OPCC workflows for [MRN].”

Next Progress Note: “On [DATE], treatment plan review completed with guardian involvement; next review scheduled.”

Collateral Contact Log: Document guardian participation if review occurred by phone.

Narrative of progress/lack of progress included

The audit showed that the treatment plan review did not contain a narrative of the child’s progress or barriers.

Root Cause: Clinician completed review fields but omitted the narrative; Epic template did not require it.

Immediate Correction: A detailed narrative of progress and lack of progress was added to the review on [DATE].

Prevention: Epic template will be updated with a mandatory “Progress Narrative” field.

Responsible Person: Clinical Supervisor ensures narratives are included; CCO oversees template update.

Due Date: 2 business days.

Verification: Supervisor reviews 10 plan reviews monthly.

Epic Fix: Plan Review SmartForm → Progress Narrative → complete.

IT Ticket: “Add mandatory Progress Narrative field to OPCC Plan Review template for [MRN].”

Next Progress Note: “On [DATE], treatment progress summarized; areas needing adjustment identified.”

Revisions documented if needed

The audit found that goals and interventions were not revised despite a lack of progress.

Root Cause: Clinician did not adjust the plan, and supervisor oversight was insufficient.

Immediate Correction: The plan was revised on [DATE] to include adjusted goals and new interventions.

Prevention: Supervisors will review progress data during each plan review and confirm revisions if progress is stalled.

Responsible Person: Clinical Supervisor monitors revisions; CCO ensures revision prompts in Epic.

Due Date: 3 business days.

Verification: Supervisor audits of plan reviews requiring revisions.

Epic Fix: Plan Review SmartForm → Revisions/Updates section → complete.

IT Ticket: “Add prompt requiring clinician to confirm revisions in OPCC Plan Review template for [MRN].”

Next Progress Note: “On [DATE], treatment plan revised to reflect new goals and updated strategies.”

Review signed by parent/guardian, child (if capable), clinician

The audit identified that the treatment plan review was not signed by the guardian.

Root Cause: The review was finalized without routing to guardian for signature.

Immediate Correction: Guardian signature was obtained and uploaded to Epic on [DATE].

Prevention: Epic workflow will be updated to require routing for guardian signature before review finalization.

Responsible Person: Clinical Supervisor confirms all required signatures; CCO enforces Epic routing; CEO provides oversight.

Due Date: Immediate, within 3 business days.

Verification: “Missing Signatures – Reviews” report reviewed weekly.

Epic Fix: Plan Review → Route for Signature → guardian, child (if capable), clinician.

IT Ticket: “Enable required signature routing for guardian/child/clinician before OPCC Plan Review finalization for [MRN].”

Next Progress Note: “On [DATE], guardian and clinician signatures obtained and uploaded for review.”

Collateral Contact Log: Document guardian confirmation if signature collected remotely.

Next review date specified

The audit revealed that the next treatment plan review date was not entered.

Root Cause: Clinician completed the review but failed to set the next review date, and Epic did not enforce scheduling.

Immediate Correction: The next review date was entered on [DATE] and a reminder task scheduled.

Prevention: Epic will require entry of the next review date before plan review can be signed.

Responsible Person: Clinical Supervisor ensures entry; CCO enforces template requirement.

Due Date: 1 business day.

Verification: Supervisor audits review schedules monthly.

Epic Fix: Plan Review SmartForm → Next Review Date field → complete and schedule task.

IT Ticket: “Add mandatory Next Review Date and task creation to OPCC Plan Review workflow for [MRN].”

Next Progress Note: “On [DATE], next treatment plan review scheduled for [DATE].”

Dated, legible, signed, credentials listed (DCF §17a-20-42(m); 42 CFR §447.10)
The audit revealed that progress notes were not signed and lacked the clinician’s credentials, violating Medicaid documentation requirements. Root Cause: The clinician did not finalize the note, and the template did not enforce credential display. Immediate Correction: On [DATE], the clinician signed the note in Epic and ensured credentials were appended. Prevention: Epic templates will be updated to auto-populate credential lines, and unsigned notes will be blocked from billing. Responsible Person: Clinical Supervisor ensures signature compliance; CCO oversees template enforcement; CEO reviews high-risk unsigned claims. Due Date: Within 1 business day. Verification: Supervisors monitor the “Unsigned Notes” Epic report daily. Epic Fix: Progress Note → click Sign Encounter; ensure credential SmartText auto-loads. IT Ticket: “Please add credential auto-insert to OPCC note templates and block unsigned notes from billing for [MRN].” Next Progress Note: “On [DATE], prior unsigned notes corrected and credentials verified.”

Supervision documented (DCF §17a-20-22)
Audit showed that required clinical supervision was missing. Root Cause: Notes from unlicensed staff were not routed for co-signature, and supervision documentation was omitted. Immediate Correction: On [DATE], the supervisor co-signed the note and documented supervision. Prevention: Epic workflows will be updated to auto-route all notes from unlicensed staff/interns to assigned supervisors for review. Responsible Person: Clinical Supervisor co-signs and verifies supervision entries; CCO configures Epic routing; CEO monitors systemic compliance. Due Date: Within 3 business days. Verification: Weekly review of the Epic “Co-Sign Completion” report. Epic Fix: Note → Add Co-Signer → Supervisor → Co-sign with supervision note. IT Ticket: “Enable automatic routing of unlicensed staff/intern notes to supervisors for co-signature in OPCC workflows [MRN].” Next Progress Note: “On [DATE], supervisory oversight documented with supervisor co-signature.”

Each service linked to treatment plan goals
Audit found that services were documented but not linked to treatment plan goals, invalidating medical necessity. Root Cause: Clinician entered free-text narrative but did not use the Linked Goal field. Immediate Correction: On [DATE], the note was amended to reference Goal #[X] from the treatment plan. Prevention: Epic templates will include a required “Linked Goal” dropdown. Responsible Person: Clinical Supervisor ensures goal linkage; CCO configures Epic field; CEO monitors risk. Due Date: Within 2 business days. Verification: Supervisors run the “Unlinked Notes” Epic report weekly. Epic Fix: Progress Note → Linked Goal dropdown → select active plan goal. IT Ticket: “Add required Linked Goal dropdown to OPCC Progress Note template for [MRN].” Next Progress Note: “On [DATE], interventions documented as addressing Goal #[X].”

Start & stop times (actual visit times)
Audit showed missing start and stop times, which are required to support billing codes. Root Cause: Clinician entered appointment time rather than actual session duration. Immediate Correction: On [DATE], the note was edited to reflect correct start/stop times under Encounter Details. Prevention: Epic templates will require time entry before note submission. Responsible Person: Clinical Supervisor reviews compliance; CCO adds template enforcement. Due Date: Same day, no later than 1 business day. Verification: “Missing Start/Stop Times” Epic report checked daily with billing scrub. Epic Fix: Progress Note → Encounter Details → enter Start and Stop Times. IT Ticket: “Require Start/Stop Times in OPCC Progress Note template before signature for [MRN].” Next Progress Note: “On [DATE], session duration corrected; times now documented accurately.”

Duration matches CPT/HCPCS code and group rules
Audit revealed CPT code did not align with documented duration or group size. Root Cause: Clinician selected incorrect CPT code; Epic Charge Router did not block mismatch. Immediate Correction: On [DATE], the CPT code was corrected in Charge Review and the claim re-submitted. Prevention: Epic Charge Router will be configured to validate CPT/time ranges and group size ≤12 participants. Responsible Person: Clinical Supervisor ensures accuracy; CCO enforces charge router; CEO approves corrections. Due Date: Immediate correction; system validation within 14 days. Verification: Pre-billing scrub for CPT/time mismatches. Epic Fix: Progress Note → confirm duration; Charge Capture → correct CPT code. IT Ticket: “Add CPT/time validation to Charge Router for OPCC encounters [MRN].” Next Progress Note: “On [DATE], CPT corrected to match documented duration; claim re-submitted.”

Only one visit per day per type/provider billed
Audit showed duplicate encounters billed for the same provider and service type on the same day. Root Cause: Duplicate claims not caught prior to submission. Immediate Correction: On [DATE], the duplicate claim was voided in Charge Review, leaving only the valid claim. Prevention: Epic rules will prevent duplicate same-day billing. Responsible Person: Clinical Supervisor checks compliance; CCO configures duplicate check; CEO reviews billing risk. Due Date: Immediate correction. Verification: Monthly duplicate billing report reviewed by CCO. Epic Fix: Charge Review → identify duplicate → void extra line. IT Ticket: “Enable same-day duplicate billing check for OPCC encounters [MRN].” Next Progress Note: “On [DATE], duplicate billing resolved; correct claim retained.”

Family therapy billed to one identified client
Audit found family therapy billed to multiple clients, violating Medicaid policy. Root Cause: Multiple MRNs billed for the same family session. Immediate Correction: On [DATE], duplicate claims were voided; only one identified client retained. Prevention: Epic billing templates will restrict family therapy billing to one identified patient. Responsible Person: Clinical Supervisor audits claims; CCO configures billing rule; CEO monitors for compliance. Due Date: Immediate correction. Verification: Monthly billing audit. Epic Fix: Charge Review → adjust billing to one MRN. IT Ticket: “Restrict family therapy billing in OPCC workflows to one identified patient per session [MRN].” Next Progress Note: “On [DATE], family therapy billing corrected under identified client only.”

Notes individualized & clinically adequate
Audit showed notes were copy-pasted and not individualized. Root Cause: Clinician used generic templates without patient-specific updates. Immediate Correction: On [DATE], notes were rewritten to reflect individualized symptoms, interventions, and responses. Prevention: Epic will reduce copy-forward functionality for psychotherapy notes and add individualized narrative prompts. Responsible Person: Clinical Supervisor ensures individualized documentation; CCO adjusts templates. Due Date: 3 business days. Verification: Random supervisor narrative audits. Epic Fix: Progress Note → edit → replace generic text with individualized details. IT Ticket: “Reduce copy-forward on OPCC psychotherapy templates; add prompts for individualized content [MRN].” Next Progress Note: “On [DATE], individualized interventions documented; unique progress noted.”

Medication list & administration instructions documented if applicable
Audit showed missing or outdated medication lists. Root Cause: Clinician did not reconcile medications at visit. Immediate Correction: On [DATE], the medication list was reconciled in Epic, and instructions were updated. Prevention: Epic workflows will include required pre-visit med reconciliation for all clients with active meds. Responsible Person: Clinical Supervisor ensures med rec compliance; CCO enforces prompt. Due Date: 2 business days. Verification: Epic Med Rec completion report. Epic Fix: Meds & Orders → Medication Reconciliation; document in Progress Note. IT Ticket: “Add med reconciliation hard stop for OPCC encounters when meds present [MRN].” Next Progress Note: “On [DATE], medication list reconciled; administration instructions documented.”

APRN collaborative agreement signed if applicable
Audit revealed APRN prescribing without a documented collaborative agreement, violating Connecticut law. Root Cause: Credentialing file was incomplete; agreement not uploaded. Immediate Correction: On [DATE], the collaborative agreement was signed and uploaded to Epic → Documents → Credentialing. Prevention: Annual tickler system will remind APRNs and supervisors of renewal dates. Responsible Person: Clinical Supervisor tracks agreements; CEO ensures credentialing compliance. Due Date: Within 7 business days. Verification: Credentialing file audit and annual compliance review. Epic Fix: Documents → Provider Credentialing → upload collaborative agreement. IT Ticket: “Add annual credentialing tickler for APRN collaborative agreements in OPCC workflows [MRN].” Next Progress Note: “On [DATE], APRN collaborative agreement uploaded and verified.”

Discharge summary within 30 days (DCF §17a-20-44)
The audit revealed that a discharge summary was not completed within 30 days of case closure, violating DCF §17a-20-44. Root Cause: The case was closed without ensuring a discharge summary was documented, and Epic did not block closure. Immediate Correction: On [DATE], the clinician completed the Discharge Summary SmartForm, including clinical summary and aftercare plan. Prevention: Epic will be configured with a hard stop to prevent closing an episode until a discharge summary is filed. Responsible Person: Clinical Supervisor monitors completion; CCO oversees Epic build; CEO reviews monthly compliance reports. Due Date: Immediate correction; systemic prevention within 5 business days. Verification: Discharge completion report reviewed monthly. Epic Fix: Navigate to Discharge Summary SmartForm → complete required fields → sign. IT Ticket: “Require Discharge Summary SmartForm before OPCC episode closure for [MRN].” Next Progress Note: “On [DATE], discharge summary finalized and filed within record.” Collateral Contact Log: Document guardian/family notification of discharge and aftercare plan.

Summary includes services, progress, remaining needs, aftercare plan
The audit showed that the discharge summary was missing one or more required elements, including aftercare planning. Root Cause: Clinician completed summary but omitted progress narrative and aftercare supports. Immediate Correction: On [DATE], the clinician amended the summary to include all required components: services provided, progress made, remaining needs, and aftercare plan. Prevention: Epic template will be updated with mandatory fields for each component. Responsible Person: Clinical Supervisor ensures completeness; CCO updates template; CEO oversees compliance. Due Date: Within 3 business days. Verification: Random audits of discharge summaries. Epic Fix: Open Discharge Summary SmartForm → complete all required narrative fields. IT Ticket: “Add mandatory fields for services, progress, remaining needs, and aftercare plan to OPCC Discharge Summary template [MRN].” Next Progress Note: “On [DATE], discharge summary amended to include all elements; guardian informed.” Collateral Contact Log: Document referral handoff to aftercare providers.

If unplanned: circumstances & clinic response documented
The audit found that an unplanned discharge occurred without documentation of circumstances or clinic response. Root Cause: Clinician closed the episode abruptly without following the unplanned discharge protocol. Immediate Correction: On [DATE], clinician documented unplanned discharge circumstances in the Discharge Summary and outlined the clinic’s response. Prevention: Epic template will include a mandatory “Unplanned Discharge” section with prompts for safety actions and follow-up. Responsible Person: Clinical Supervisor ensures protocol is followed; CCO updates template; CEO monitors compliance trends. Due Date: Within 2 business days. Verification: Supervisor review of unplanned discharge files monthly. Epic Fix: Discharge Summary → complete Unplanned Discharge section → save/sign. IT Ticket: “Add required Unplanned Discharge field to OPCC Discharge Summary template [MRN].” Next Progress Note: “On [DATE], unplanned discharge documented; guardian contacted and referrals provided.” Collateral Contact Log: Record outreach attempts to guardian and follow-up with community supports.

Continuity of care & case management documented (DCF §17a-20-44(f); 42 CFR §438.208)
The audit revealed that continuity of care and aftercare linkage were not documented in the discharge summary, violating DCF §17a-20-44(f) and Medicaid continuity of care standards. Root Cause: Clinician did not enter referrals or follow-up linkage, and collateral contacts with aftercare providers were missing. Immediate Correction: On [DATE], clinician updated discharge summary to include referral details, aftercare appointments, and case management coordination; collateral contact notes were entered for calls to providers. Prevention: Epic workflows will require completion of Aftercare/Continuity fields before discharge is finalized. Responsible Person: Clinical Supervisor ensures compliance; CCO configures Epic template; CEO reviews continuity outcomes quarterly. Due Date: Within 3 business days. Verification: Discharge linkage audit and aftercare report monitoring. Epic Fix: Discharge Summary → Aftercare/Case Management → complete required fields. IT Ticket: “Add required aftercare linkage and case management fields to OPCC Discharge Summary [MRN].” Next Progress Note: “On [DATE], continuity of care documented and aftercare linkage confirmed.” Collateral Contact Log: Record confirmation with guardian and aftercare providers.

Services billed match documentation (42 CFR §455.18; Ch. 7 Clinic Manual)
The audit revealed that services billed did not match what was documented in the progress note, a direct violation of Medicaid billing standards. Root Cause: Clinician submitted note missing required details, and billing staff processed the claim without cross-checking. Immediate Correction: On [DATE], the note was amended to reflect accurate service details, and the incorrect claim was voided and resubmitted with the corrected CPT code. Prevention: Epic billing workflow will enforce a documentation check before claim submission. Supervisors will review documentation-to-claim consistency weekly. Responsible Person: Clinical Supervisor ensures notes support billing; CCO enforces claim validation; CEO oversees compliance with Medicaid billing audits. Due Date: Immediate correction; systemic prevention within 14 days. Verification: Documentation-to-claim audit prior to billing submission. Epic Fix: Progress Note → edit narrative to support service; Charge Review → correct claim. IT Ticket: “Enable documentation check in Epic billing workflow to prevent submission of claims not supported by clinical documentation for OPCC [MRN].” Next Progress Note: “On [DATE], billing documentation corrected and aligned with submitted claim.”

Only qualified staff documented as rendering service (DCF §17a-20-22; 42 CFR §440.90)
The audit revealed that services were billed under unqualified staff, violating Medicaid rules. Root Cause: Rendering provider was documented incorrectly, or intern note was not co-signed. Immediate Correction: On [DATE], the rendering provider was corrected in Charge Review, and the claim was resubmitted under a licensed clinician. Prevention: Epic workflows will restrict billing privileges to licensed staff or supervised interns. Credentialing oversight will be updated. Responsible Person: Clinical Supervisor verifies claims accuracy; CCO enforces credentialing rules in Epic; CEO monitors systemic compliance. Due Date: Immediate for claim correction; 14 days for Epic workflow changes. Verification: Weekly rendering provider compliance reports. Epic Fix: Charge Review → update rendering provider field. IT Ticket: “Restrict rendering provider field in OPCC workflows to licensed clinicians or supervised interns only for [MRN].” Next Progress Note: “On [DATE], rendering provider corrected; service confirmed as provided by licensed staff.”

Supervision of unlicensed staff/interns documented (DCF §17a-20-22(c); 42 CFR §438.214)
The audit found that services delivered by interns or unlicensed staff were not documented as supervised, invalidating billing. Root Cause: Supervisor did not co-sign intern notes, and Epic did not auto-route notes for co-signature. Immediate Correction: On [DATE], supervisor co-signed all outstanding notes, and supervision documentation was added. Prevention: Epic will automatically route all unlicensed staff/intern notes to assigned supervisors for co-signature within 7 days. Responsible Person: Clinical Supervisor documents supervision; CCO configures routing rules; CEO monitors systemic compliance. Due Date: Within 3 business days for corrections; permanent routing in 14 days. Verification: Weekly Epic “Co-Sign Completion” report. Epic Fix: Progress Note → Add Co-Signer → Supervisor signs with supervision statement. IT Ticket: “Enable auto-routing of OPCC notes from interns/unlicensed staff to assigned supervisors for co-signature [MRN].” Next Progress Note: “On [DATE], supervisory oversight documented and co-signatures completed.”

No duplicate billing across programs/payers (42 CFR §447.10(e))
The audit revealed duplicate billing for the same date of service across OPCC and another program, violating Medicaid anti-duplication rules. Root Cause: Lack of cross-program billing validation in Epic and staff oversight. Immediate Correction: On [DATE], the duplicate claim was voided, and Medicaid was refunded where necessary. Prevention: Epic charge router will be updated with cross-program duplicate detection. Responsible Person: CCO configures Epic claim logic; Clinical Supervisor reviews claims; CEO oversees reporting to Medicaid if repayment is required. Due Date: Immediate for claim corrections; systemic changes within 30 days. Verification: Monthly duplicate billing audits. Epic Fix: Charge Review Workqueue → identify duplicate → void incorrect claim. IT Ticket: “Enable cross-program duplicate detection in Epic Charge Router for OPCC claims [MRN].” Next Progress Note: “On [DATE], duplicate billing corrected; Medicaid notified as required.”

Documentation ties to treatment plan & medical necessity (42 CFR §440.230)
The audit showed that services were billed without clear linkage to treatment plan goals or medical necessity, violating Medicaid’s core requirement. Root Cause: Clinician failed to use the Linked Goal field in notes, and Epic did not require a medical necessity narrative. Immediate Correction: On [DATE], the note was amended to include linkage to Goal #[X] and justification of medical necessity. Prevention: Epic note templates will be updated with mandatory Linked Goal and Medical Necessity fields. Responsible Person: Clinical Supervisor reviews linkage; CCO enforces template build; CEO monitors compliance. Due Date: 2 business days for corrections; Epic build within 14 days. Verification: Supervisors run “Unlinked Notes” report; compliance officer reviews medical necessity entries monthly. Epic Fix: Progress Note → Linked Goal → select active treatment plan goal; add Medical Necessity narrative. IT Ticket: “Add required Linked Goal and Medical Necessity fields to OPCC Progress Note templates for [MRN].” Next Progress Note: “On [DATE], service documented as medically necessary and linked to Goal #[X].”

Section A: Intake & Admission
Referral source documented – Recoupment Not Likely (does not directly invalidate claim, but flagged as compliance weakness).
Pre-admission/referral data included – Recoupment Possible (if admission rationale absent, Medicaid may challenge medical necessity).
Informed consent signed before/at first session – Recoupment Required (services billed before consent = unallowable).
Patient rights explained & documented – Recoupment Possible (deficiency may lead to corrective action but not automatic repayment unless tied to due process violation).
Grievance procedure signed – Recoupment Not Likely (regulatory requirement; risk is sanctions, not repayment).
Confidentiality acknowledgment – Recoupment Possible/Required if absence undermines HIPAA/42 CFR Part 2; OIG may claw back if privacy breach tied to billing.

Section B: Assessment
Assessment at admission – Recoupment Required (no assessment = no proof of medical necessity).
Methods/tests & scores – Recoupment Possible (if goals/services unsupported, claims may be questioned).
Biopsychosocial history – Recoupment Required (Medicaid requires comprehensive eval; absence = invalid claim).
Strengths & weaknesses – Recoupment Not Likely (audit finding; doesn’t void claim, but corrective training required).
Family/guardian involvement – Recoupment Possible (DCF could flag, but Medicaid usually requires CAP not repayment).
Mental status exam – Recoupment Required if missing at admission; evaluation incomplete = no payable service.
Psychosocial history – Recoupment Possible (if incomplete, may be treated as insufficient medical necessity).
Medication history reviewed – Recoupment Possible (if meds not reconciled, risk is clinical liability more than billing).
Labs/diagnostics reviewed – Recoupment Not Likely unless labs ordered and not addressed.
Diagnosis & formulation documented – Recoupment Required (no diagnosis = no payable claim).
Signed by clinician w/ credentials – Recoupment Required (unsigned = invalid claim).
APRN/MD evaluation if meds – Recoupment Required (unlicensed prescribing = invalid claim).
Medical necessity clearly established – Recoupment Required (CMS/OIG will deny claim if necessity not documented).

Section C: Initial Treatment Plan
Diagnosis included – Recoupment Required (no diagnosis = invalid claim).
Type/amount/frequency/duration of services – Recoupment Required (federal Medicaid requires service specification).
Measurable goals/objectives – Recoupment Possible (plan vague = “unsubstantiated medical necessity”).
Referrals/responsible parties – Recoupment Not Likely, unless coordination billed separately.
Strengths/limitations identified – Recoupment Not Likely (quality compliance issue).
Discharge criteria – Recoupment Possible (if missing, Medicaid may deny extended stay claims).
Supports/resources for discharge – Recoupment Not Likely (compliance weakness, not billing error).
Anticipated discharge date – Recoupment Not Likely (regulatory requirement, not billing-critical).
Signatures (parent/child/clinician/admin) – Recoupment Required (no signatures = no valid treatment plan = no payable claim).

Section D: Treatment Plan Reviews
Completed every 90 days – Recoupment Required (services billed without current plan = disallowed).
Narrative of progress – Recoupment Possible (if absent, Medicaid may disallow ongoing billing).
Revisions documented if needed – Recoupment Not Likely, unless stagnation documented as “no medical necessity.”
Signatures on review – Recoupment Required (unsigned review = invalid claim).
Next review date specified – Recoupment Not Likely (compliance issue, not repayment trigger).

Section E: Progress Notes
Signed/dated/credentials – Recoupment Required (unsigned = unbillable).
Supervision documented – Recoupment Required (intern/associate without supervision = invalid claim).
Linked to treatment plan goals – Recoupment Required (Medicaid requires linkage to plan/necessity).
Start & stop times – Recoupment Required (duration mismatch invalidates CPT).
Duration matches CPT code – Recoupment Required (over/under billing triggers repayment).
Only one visit per day – Recoupment Required (duplicate billing = fraud risk).
Family therapy billed correctly – Recoupment Required (double-billing family = Medicaid recoupment).
Individualized/clinically adequate – Recoupment Possible (copy-paste may cause denial if pervasive).
Medication list/instructions – Recoupment Possible, but more compliance/safety than billing.
APRN collaborative agreement – Recoupment Required if APRN billed without valid supervision agreement.

Section F: Discharge
Discharge summary within 30 days – Recoupment Required (services after closure may be disallowed).
Summary includes services/progress/aftercare – Recoupment Possible (risk = insufficient continuity).
Unplanned discharge documented – Recoupment Not Likely, but regulatory sanction risk.
Continuity/case management documented – Recoupment Possible if aftercare billed separately.

Section G: Medicaid Billing Integrity
Services billed match documentation – Recoupment Required (Medicaid recoups every unmatched claim).
Qualified staff billed – Recoupment Required (services by non-qualified staff = invalid).
Supervision documented – Recoupment Required (intern/associate without supervision = disallowed).
No duplicate billing – Recoupment Required (duplicates = repayment + possible fraud flag).
Documentation ties to medical necessity – Recoupment Required (Medicaid will claw back claims if necessity is not established).

🔑 Summary of Financial Exposure
High Risk (Automatic Recoupment): Consent, assessments, unsigned notes, diagnosis, treatment plan reviews/signatures, supervision, CPT/time mismatches, duplicate billing, medical necessity.
Moderate Risk (Possible Recoupment): Missing pre-admission data, progress narratives, discharge planning gaps, family involvement, vague goals.
Low Risk (Compliance Only): Referral source, grievance form, strengths/limitations, anticipated discharge date.