Table of Contents
Ready to See Results?
From strategy through execution, Atlantic Health Strategies integrates compliance, operations, and growth into durable, measurable results. Let’s put our expertise to work for your organization.
The Five Findings Surveyors Keep Writing
Behavioral health surveyors keep writing the same five findings on treatment center reports: incomplete personnel files, policies that staff cannot describe out loud, thin ASAM level-of-care documentation, mishandled incident reports, and compliance treated as a project instead of an operating function. None of these are exotic. All of them are avoidable. Joint Commission, CARF, Florida AHCA, and Florida DCF surveyors write these deficiencies with predictable frequency.
Two weeks ago I walked an EOC tour of a 32-bed residential facility in Palm Beach County. The prior surveyor, before the operator hired Atlantic, pulled three personnel files at random. All three were missing primary source verifications. One file was missing the Level 2 background screening clearance letter from AHCA’s own Care Provider Background Screening Clearinghouse. The operator paid roughly $2,000 in AHCA fees, plus two weeks of executive bandwidth, over a problem the HR lead should have caught at hire.
The federal enforcement backdrop makes the stakes worse. HHS-OIG’s FY 2024 MFCU report shows Medicaid Fraud Control Units recovered $1.4 billion, obtained 1,151 convictions, and drove 1,042 exclusions from federally funded programs, at a return of $3.46 for every $1 spent. On June 30, 2025, DOJ announced its 2025 National Health Care Fraud Takedown, charging 324 defendants across 50 federal districts and 12 State Attorneys General’s Offices in schemes involving over $14.6 billion in intended loss. Attorney General Pamela Bondi called it a “record-setting Health Care Fraud Takedown.” What follows is the operator-side playbook for each of the five.
Personnel Files and Policy-to-Practice Gaps
Personnel files are the single most common finding I see, and it is not because operators do not care. Founders hand HR to whoever has bandwidth, usually a clinical director already carrying a caseload. Personnel files are not a clinical document. They are a regulatory document. Florida DCF, AHCA, and Joint Commission surveyors read them the same way: if it is not in the file, it did not happen.
Under Florida law, AHCA requires a Level 2 fingerprint-based background check initiated through the Clearinghouse, with an eligibility determination before an employee starts work. Providers licensed or regulated by AHCA must complete Level 2 screening for new hires within 10 business days of hire, and evidence of screening must be retained in the personnel files for those screened. Miss the paperwork and the surveyor has a finding before opening the chart. We run quarterly file audits for our MSO clients and catch an average of 11 missing documents per 25-person staff. Every one of those would have been a citation.
The policy problem is close behind. A CARF surveyor in Broward County last year asked a BHT to describe the seclusion and restraint policy. The BHT admitted he did not know it, even though a compliant policy sat in the binder. That answer dropped the operator from a three-year to a one-year accreditation. Per Joint Commission’s own tracer methodology guidance, surveyors follow “the experience of care, treatment, or services for a number of patients through the organization’s entire care delivery process” and interview frontline staff along the way. When staff answers do not match the binder, the surveyor writes the finding.
Operators do not need better policies. Operators need shorter policies that match real workflow, paired with documented competency checks. If the med pass policy says one thing and the nurses do another, rewrite the policy to match the safer practice, then retrain until every nurse can describe it out loud.
ASAM Level-of-Care Documentation That Actually Defends Itself
This one costs operators the most money. It shows up in two places: state surveys and payer SIU audits. Under the ASAM Criteria 4th Edition, every admission and continued stay must document the dimensional assessment that justifies the level of care. Six dimensions. Not four.
I reviewed charts at a Florida PHP (an outpatient level, ASAM Level 2.5) where the clinician’s justification for stepping the patient down from a residential level was a single sentence: “patient stable.” That is a $38,000 clawback waiting to happen when a payer’s Special Investigations Unit runs a retrospective review. UR reviewers read the chart looking for evidence in every dimension. A note that hits four dimensions and skips two often gets a denial.
The most commonly skipped dimensions are Dimension 4 (readiness to change) and Dimension 6 (recovery environment), because they feel social rather than medical. They are not optional. Florida AHCA surveyors increasingly cross-reference utilization management documentation against the clinical record. If the UR team writes one story to the payer and the therapists write a different story in the progress notes, the surveyor sees it. The payer SIU sees it later. Both act.
Train clinical leadership to write to the ASAM dimensions explicitly. Name Dimension 1, Dimension 2, Dimension 3 in the note. It feels formulaic. Surveyors and payers reward it because it is defensible. If clinical leaders are not using ASAM-aligned templates or an equivalent structured tool, they are writing blind.
Incident Reports That Do Not Read Like a Cover-Up
Florida DCF requires critical incidents to be reported through the Incident Reporting and Analysis System (IRAS) as a condition of licensure under Chapter 65D-30, Florida Administrative Code. Per CFOP 215-6, “all critical incidents must be entered into IRAS within one business day of the incident occurring,” and DCF states that compliance with the procedure is a condition of substance abuse licensure regardless of whether the provider serves DCF-funded clients.
I have watched operators miss the window because the on-call administrator did not know which category applied. I have also watched operators self-inflict damage by writing incident reports that minimize what happened. A case I reviewed in Pasco County: a facility documented a 14-hour patient elopement as a “brief unauthorized absence.” The patient was found in another county. DCF investigators found the report. The licensure consequences were significant.
The federal picture is worse. HHS-OIG reported that criminal recoveries in FY 2024 hit $961 million, the highest amount over the past 10 years and more than double the rolling 5-year average. DOJ’s 2025 Takedown more than doubled the prior record of $6 billion set in 2020, making it the largest health care fraud takedown in Department of Justice history.
Surveyors and prosecutors are not stupid. When the incident narrative does not match the nursing note, which does not match the security log, which does not match the discharge summary, they see it. Then everything else in the chart gets scrutinized. Write incident reports the way you would want them read aloud in a deposition. Factual, timestamped, and consistent with every other document in the record. The cover-up always costs more than the incident.
Compliance Is an Operating Function, Not a Project
Here is the pattern I see in nearly every turnaround AHS takes on. The founder hired a consultant 90 days before the initial AHCA licensure survey. Their team passed. Then everyone went back to running the business. Eighteen months later the biennial survey hit, and 23 findings appeared because no one owned compliance in the interim.
Operators should treat compliance as an operating function with a calendar, an owner, and a budget line. For a 50-bed multi-site operator in Florida or Tennessee, I see that budget line land between $60,000 and $200,000 annually depending on whether the CEO builds internally or contracts through an MSO. Operators who treat it as a fixed cost sleep at night. Operators who treat it as a one-time spend get the 3 a.m. Call from their DON.
The enforcement math supports the fixed-cost view. HHS-OIG reports that 53 MFCUs operated in all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands in FY 2024, recovering $3.46 for every $1 spent. DOJ’s June 30, 2025 announcement noted that the government seized over $245 million in cash, luxury vehicles, cryptocurrency, and other assets as part of the coordinated enforcement efforts. That money comes from providers who could not defend their documentation.
Run mock surveys at least twice a year. Audit charts monthly. Review personnel files quarterly. Walk your own EOC with a clipboard the week before any scheduled inspection. None of this is glamorous. All of it is the difference between a clean survey report and a plan of correction that eats your Q3.
Frequently asked questions
What are the most common findings on Joint Commission behavioral health surveys?
Personnel file and competency documentation, medication management, environment of care, informed consent, and leadership and policy oversight dominate the list. Per Joint Commission’s published guidance, surveyors use tracer methodology to follow individual patients through the entire care delivery process and interview frontline staff along the way. When staff answers do not match the binder, the surveyor writes the finding.
How quickly must a Florida-licensed substance abuse provider report a critical incident?
Under Chapter 65D-30, Florida Administrative Code, and DCF operating procedure CFOP 215-6, all critical incidents must be entered into DCF’s Incident Reporting and Analysis System (IRAS) within one business day of the incident occurring. Per DCF, compliance with CFOP 215-6 is a condition of substance abuse licensure regardless of whether the provider serves DCF-funded clients.
How should operators document ASAM level of care to survive a payer SIU audit?
Under the ASAM Criteria 4th Edition, every admission and continued stay must be justified across all six dimensions of the dimensional admission criteria. Skipping Dimension 4 (readiness to change) or Dimension 6 (recovery environment, including social determinants) is the fastest path to a denial or clawback. Have UR and clinical staff write to the same dimensional narrative, and cite each dimension by number in the note.
What does federal enforcement risk look like for behavioral health operators right now?
HHS-OIG’s FY 2024 MFCU Annual Report shows MFCUs recovered $1.4 billion, obtained 1,151 convictions (817 fraud, 334 patient abuse or neglect), and drove 1,042 exclusions from federally funded programs, at a return of $3.46 for every $1 spent. On June 30, 2025, DOJ’s National Health Care Fraud Takedown charged 324 defendants across 50 federal districts and 12 State Attorneys General’s Offices in schemes involving over $14.6 billion in intended loss, more than doubling the prior $6 billion record set in 2020. State-level enforcement runs in parallel, and documentation is the primary defense.
References
- HHS-OIG, Medicaid Fraud Control Units Annual Report: Fiscal Year 2024
- U.S. Department of Justice, 2025 National Health Care Fraud Takedown (June 30, 2025)
- Florida Agency for Health Care Administration, Background Screening Unit and Care Provider Background Screening Clearinghouse
- Florida DCF, CFOP 215-6, Incident Reporting and Analysis System (IRAS)
- The Joint Commission, What is the Tracer Methodology?
- Florida DCF, Incident Reporting and Analysis System (IRAS) Overview
- Epstein Becker Green, Analysis of the 2025 National Health Care Fraud Takedown