Despite the client’s history of suicide attempts and ongoing suicidal ideation, the therapist did not adequately document or implement a safety plan.
When a client exhibits self-harming behaviors or describes other suicide risk factors, conduct and document a thorough risk assessment and safety plan.
Consider the Columbia Suicide Severity Rating Scale (C-SSRS)
No informed consent was present in the client’s records.
Progress failed to include session mode (audio, video, etc.), client location verification, and emergency contacts.
Telehealth sessions must verify the client's location at the start of the session.
Notes lacked proper signatures and confirmation of compliance with Arizona Board standards.
The informed consent did not clearly specify the type of service (individual, family, couples, etc.) or the individuals involved in therapy.
Several family members, including minors, participated in therapy without documented consent.
The therapist provided therapy to multiple members of a conflicted family unit without clarifying roles or relationships. This represents a conflict of interest/dual relationship.
Treatment plans were missing review dates and client signatures.
Ensure the review date is explicitly written out next to the treatment goal, especially if using Simple Practice.
Treatment plans must be signed by all parties involved in treatment and the therapist.
Billing records had inconsistencies.
The therapist billed for individual therapy using a 90834 CPT code when multiple participants were involved. The therapist most likely should have used a 90847 CPT code. Alternatively, the therapist could have billed for individual sessions if participants were visitors, but no visitors/collateral form was on file, and based on the session content, was probably not justified.
Some sessions did not have a corresponding billing record, and visa versa.
The complainant was abruptly discharged from therapy without proper notice or referral.
The therapist was instructed by their practice to refer to insurance, which is insufficient. Additionally, the complainant reached out regarding their discharge, and the therapist suggested that the administration staff handled the discharge.
Therapists should clearly discuss termination and provide appropriate referrals to clients.
The therapist acted beyond a counselor's role by engaging in mediation-type activities, such as enforcing court-ordered parenting time and coordinating child exchanges.
These activities were outside the scope of competency and represent a dual relationship/conflict of interest.
Therapist fraudulently represented their completion of continuing education during the license renewals.
Therapists may be audited randomly by the board, so ensure that you maintain records of all continuing education certificates received.