General Compliance & Incident Reporting
Q. What does the Compliance & Regulations Department do?
A. The Compliance & Regulations (C&R) Department is responsible for ensuring that services are delivered in accordance with applicable laws, regulations, and agency policies. The department provides oversight, conducts investigations, reviews Witness Participation forms, inputs Incident Reports, and promotes safe, ethical, and compliant practices across the organization.
Q. What qualifies as an Incident?
A. An incident is any event that may impact the member’s safety, health, rights, emotional well-being, or quality of care. Examples include injuries, medication errors, behavioral crises, neglect concerns, restrictive interventions, missing persons, or any allegation of abuse or exploitation.
If you are unsure — report it. The C&R team will determine the correct classification.
Q. When should I report an Incident?
A. Incidents should be reported immediately after they occur or as soon as they are discovered. Prompt reporting ensures member safety, compliance with regulatory requirements, and timely investigation and follow-up.
Q. How do I report an Incident?
A. Use the Witness Participation Form (If you are a Vendor use Witness Participation Form-Vendor) found in Setworks in the member’s profile.
Q. What information should I include when documenting an Incident?
A. Keep documentation factual, objective, and detailed. Include:
Who was involved
What happened (in clear, direct terms)
When and where the incident occurred
Immediate actions taken to support the member
Notifications made (supervisor, guardian, emergency services, etc.)
Avoid assumptions, interpretations, or personal opinions.
Q. Where can I find the Witness Participation Form?
A. Follow the steps listed below.
Log into Setworks.
Select the Individual tab located at the top left of the page.
In the search field, enter the member’s name (last name first).
Once the member’s profile opens, scroll to the bottom of the page.
On the left side, click the Forms tab.
From the drop-down menu, select Witness Participation Form.
Complete all required fields in the form by following the prompts.
When finished, click Submit to complete your submission.
Q. How long does an investigation take?
A. The length of an investigation varies depending on the complexity of the situation. Some matters may be resolved quickly, while others require additional interviews, documentation, or regulatory consultation. You will be notified of outcomes when the review is complete.
Q. Why might I be placed on administrative suspension?
A. Administrative suspension is used to allow a fair and neutral investigation. It is not a presumption of wrongdoing. Suspension length depends on the details of the case. The C&R team will notify the appropriate departments of the outcome of the investigation.
Q. How long am I on suspension?
A. If you are placed on administrative suspension during an investigation, the duration will vary depending on the circumstances and complexity of the case. You will be notified by Human Resources, Personnel, or your direct supervisor once the review is complete and a determination has been made. Please refrain from contacting individuals involved in the matter while the investigation is ongoing. The Compliance & Regulations team does not handle staff disciplinary actions, but will direct you to HR, Personnel, or your supervisor.
Q. Who should I contact if I have questions about reporting or compliance requirements?
A. Contact the Compliance & Regulations Department at asncr@supports.org or your direct supervisor for guidance. The earlier questions are addressed, the better the outcome for the member and the team.
Audits
Q. Why is accurate documentation so important?
A. Documentation (example: Daily Activity Records, Communication notes, etc.) is a main part explaining the service delivery. It shows what support was provided, how the member’s needs were met, and ensures the organization remains compliant with state and waiver requirements. If it isn’t documented, it is considered not done.
Q. What is an audit?
A. An audit is a formal review of documentation, records, and practices to ensure the agency is meeting regulatory standards and service expectations. ASN conducts internal audits (completed by the agency). ASN is also subject to external audits (completed by the state, waiver oversight, and funders) audits.
Q. When do audits happen?
A. ASN conducts daily internal audits of individual service files to ensure compliance. External audits, which are typically unannounced, occur periodically throughout the year.
Q. Why does our agency do internal audits?
A. Internal audits help identify areas needing support or correction before a state or regulatory review occurs. They are designed to strengthen services, protect individuals receiving services, and reduce risk, not to punish staff. Internal audits help to identify areas of improvement and ensure proper documentation is on file for persons receiving services as well as staff.
Q. Who conducts external periodic audits?
A. The external audits are conducted by PASSE providers Arkansas Total Care, Empower, & Summit; the Division of Developmental Disabilities Services Quality Assurance (DDSQA); Medicaid Program Integrity (MPI); Division of Provider Services and Quality Assurance (DPSQA).
Q. What documentation is reviewed during an audit?
A. External & internal audits review Individual Setwork files, the entire file, including Activity Records, Medication and travel logs, Facesheets,Service Assessments, Behavioral Health Plans, valid identification for members, birth certificates, PASSE/Medicaid/Social Security cards, Guardianship/Court documentation, member’s emergency contact information. Staff's employment records include valid identification documents, Activity Records, current CPR and First Aid Certificates and Open Future Learning training records.
Q. What happens if documentation is missing or incomplete during an audit?
A. Missing or incomplete documentation may result in any of the following:
Non-compliance findings
Corrective action requirements
Repayment or loss of funding
Risk to the provider’s licensure and ability to serve members
Consistent, timely documentation prevents these issues.
Q. When should documentation be completed?
A. Documentation must be completed the same day the support or service is provided, ideally immediately after the task or interaction (before your shift ends). Late entries should be uncommon, as they delay back-office processes and may impact timely payroll and billing. Completing documentation on time protects both you and the individuals we support.
Q. What should good documentation include?
A. Good documentation includes the following information:
Accuracy (reflects what actually occurred)
Objective (free of opinions, assumptions, or personal feelings)
Complete (addresses all required areas)
Timely (entered on the day of the service)
Focus on the following: who, what, when, where, and how the support was provided. Remember good documentation is not about your feelings or opinions, only include what actually happened & the services you contributed.
Q. What if I’m not sure how to document something?
A. If you’re unsure, ask. Your direct Supervisors, the DSP Development Team, the Personnel Team, & Compliance & Regulations department are available to guide you. It’s better to clarify documentation expectations than make an incorrect entry.
Q. How do audits benefit the individuals we support?
A. Audits help ensure:
The Individual’s needs are consistently being met
The Individual’s rights and safety are protected
Services remain person-centered
Care plans truly reflect the support needs of the person receiving services
Proper documentation supports high-quality, individualized services.
Q. What is my responsibility during an audit?
A. Your responsibility is to:
Provide requested documentation promptly and accurately
Answer questions to the best of your knowledge
Update or correct records if directed
Participate in training if needed
Audits are designed to support quality improvement, not to discipline staff. One of the best ways to contribute to a smooth audit process is by completing daily activity records and ensuring monthly, six-month, and annual documentation is submitted on time. This helps demonstrate the great work you do and ensures continued quality services for the individuals we support.