Corporate Compliance

THE ARC, ONEIDA-LEWIS COMPLIANCE STANDARDS

All employees of The Arc, Oneida-Lewis are expected to comply with the agency’s Corporate Compliance standards.

The following is a list of some of the agency’s standards:

  • Employees must not make false entries in any of the agency’s records or in any public record for any reason
  • Documentation of plan implementation must be completed prior to the end of shift. As extenuating circumstances may occur, in those situations, documentation must be completed within 24 hours.
  • Plans must be implemented according to the identified frequency.
  • Employees will document only for the services that he or she provided.
  • Permanent entries in the agency’s records cannot be altered. Errors should be crossed out with a single line, initialed and dated. The use of “white out” is not permitted. Corrections made in the electronic health record must include a clear reason for the correction.
  • Employees shall not create or participate in the creation of any records that are intended to mislead or conceal anything that is improper.
  • Documentation should be prepared contemporaneously with the provision of services and should be consistent with the applicable third party payors’ requirements for documentation and any other regulatory requirements.
  • Documentation must include required elements, and must be made in ink, permanent and legible. Late entries must be dated as such.
  • Completion of time sensitive compliance related job tasks must be done prior to planned leave time.
  • Supervisors/managers will complete required review of documentation in a timely manner and in accordance with programmatic time frames. Supervisors will monitor adherence to compliance standards on an on-going basis.

Documentation Do’s and Don’ts

DO:

• Document legibly in blue or black ink

• Document only for services you provide

• Sign and Date all Entries

• Document the complete date-Month/Day/Year

• Document with your full title

• Include date with your signature

• Correct Errors with a Single line-date-initial

• Document promptly before end of shift

• Ensure documentation is accurate

• Only submit claims for services provided

• Obtain proper authorization for services

• Completely fill out all forms

DON’T

• Document someone else’s work

• Use white out

• Scribble over or attempt to obliterate errors

• Back date documents

• Re-write or recreate notes without transparency

• Use pencil

• Leave labeled fields blank

• Alter previous documentation

• Use someone else’s Therap log in

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