- (a) The therapeutic community shall have a policy and procedure mandating the chronological documentation of progress notes for clients admitted to therapeutic communities.
(b)
- (1) All services provided to a client shall be documented in a daily service log to indicate when particular services were provided to clients.
(2)
- (A) This daily log shall also include a daily summary indicating the goals and objectives within the plan of care that were addressed during treatment during the day.
- (B) This summary shall include the:
(i) Activities performed; and
- (ii) Client’s progress or lack of progress of achieving the treatment goal or goals established in the individualized plan of care.
- (3) This daily service log shall be reviewed and signed by a mental health professional (independently licensed practitioner, nonindependently licensed practitioner).
(4) This daily service log must be:
- (A) Easily accessible to any auditors; and
(B) Updated and signed daily by appropriate staff.
- (c) Progress notes shall be documented according to the following time frames: therapeutic community staff shall document progress notes daily.