{"ref":"FL-HC-RM-02","title":"Service Documentation and Accurate Records","category":"Records","summary":"Sets how direct care staff and supervisors document every visit, what a visit record shows, how entries are corrected and late entries made, how records are turned in and reviewed before billing, and the Florida prohibitions on fraudulent records (charting ahead, recording what was not personally observed, borrowing records, falsifying signatures), with the fines a licensed agency faces for patterns of false records, billing for services not provided, and failing to provide agreed services.","inShort":["Fill in the visit record during the visit and finish it before you leave the home.","Write only what you did and saw yourself, at the time it happened. Never fill anything in ahead of time.","Write your real arrival and departure times, not the scheduled times.","Never sign for anyone else, and never ask a client to sign a blank record or several days at once.","To fix a mistake, draw one line through it, write the correct entry, the date and your initials. Never erase or use correction fluid.","Turn in paper visit records at least once a week."],"primaryCitation":"s. 400.474(2)(d), F.S.","citations":["s. 400.474(2)(d), (3)-(5), F.S.","Rule 59A-8.0095(3)(d), (5)(l)4-5, (12)(a)5-7, (12)(b)6-7, F.A.C.","s. 400.488(3)(f), F.S.","Rule 59A-8.025(8)(d), F.A.C.","s. 400.492(3), F.S.","s. 409.913, F.S.","s. 409.9132, F.S.","Rule 59A-8.022(6)(b), F.A.C."],"federalCitations":["42 U.S.C. §1396b(l)"],"surveyorAsks":["Show me the visit records for this client for last month. Do they match the schedule and the bills?","How do you know your staff did not complete these records ahead of time?"],"forms":[{"ref":"FL-HC-RM-02-A","title":"Visit and Service Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (s. 400.474(2)(d), F.S.)","5. Who Documents What","6. What Every Visit Record Shows","7. Accurate Records: What Is Never Allowed","8. Timing, Corrections, and Late Entries","9. Turning In and Reviewing Records","10. Plain and Useful Records","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"fl-hca","state":"Florida","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}