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