Behavioral Health Deficiencies Tied to Documentation Issues

By: Teresa Hoosier, RN, CDN, Associate Clinical Director 

Teresa Hoosier leads ACHC’s Behavioral Health, Assisted Living, and Renal Dialysis Accreditation programs. Her knowledge of interdisciplinary coordinated care makes her a great resource to organizations seeking a knowledgeable, practical partner in improving quality.  

Teresa’s expertise encompasses clinical compliance, quality assurance, policy and procedure development, and clinical training and education. She is committed to building a support system for accreditation, so that you can focus more on providing the support your clients need. 

Posted: December 1, 2025

From prevention services to residential treatment, documentation is vital to protect vulnerable clients and support risk management for behavioral health organizations. But all too often, documentation falls short, leading to gaps and inconsistencies that can compromise quality of care. 

Survey findings in the latest Quality Review edition of Surveyor fault documentation failings for many of the top deficiencies noted during our recent reporting period

Of the 10 most commonly cited ACHC Behavioral Health Accreditation Standards, seven come from Section 5: Provision of Care and Record Management. This section lies at the heart of behavioral health services and reflects how treatment/interventions are planned, delivered, and documented. 

Other standards cited pertain to operational requirements, including establishing policies and procedures that respect the rights, dignity, and safety of service recipients.  

New this year

Continuous improvement is woven into all we do at ACHC, including the annual Quality Review edition of Surveyor. In our recent issue, “tips for compliance under each standard profile are enhanced to address varying levels of accreditation knowledge and experience across your agency. Explore our new Accreditation Nerd categories to see which is best for you. 


Discover more articles about Behavioral Health Accreditation.