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Documenting Corporate Compliance

Documenting Corporate Compliance

A well designed corporate compliance program requires comprehensive documentation.  Documentation is important in measuring the effectiveness of the program and provides a framework for continual improvement. It is essential in avoiding and defending against legal actions and provides a safer, more secure, work environment.

Compliance documentation includes:

  • Written Policies and Procedures
  • Distribution and Acknowledgment
  • Training
  • Deviation Reporting
  • Resolutions
  • Reviews


Creating Policies and Procedures

The backbone of your ethics and compliance program includes well written policies and procedures.  Your policies and procedures must be written clearly, with attention to detail, so as not to leave any room for interpretation.  It’s best to start with a template designed specifically to meet CARF® guidelines.  Templates are designed to be customized, specific to your organizations practices.  The Code of Ethics/Conduct policy provides the basis of your compliance program.  However, your policies related to health and safety, risk management, human resources, rights of persons served, etc. all play an important role in your overall compliance program.

A good internet based document management system will allow collaborating team members to easily provide input on documents as they are being created.


Understanding and Acknowledgment

It is important that systems are put in place to document the clear understanding of your compliance program.  All personnel should have access to your Code of Ethics/Compliance and other relevant policies and procedures. Acknowledgement of these documents assists in providing assurances that personnel have been trained in identifying and reporting suspected deviations from ethical expectations. You will want to secure acknowledgement at hire and anytime a change is made.  Historically, new hires were instructed to read and sign individual forms.  When a change was made, it was up to the supervisor to seek out, and gain acknowledgement from individuals, personally.  Fortunately, the days of time consumptive, paper signatures, is a thing of past. An electronic acknowledgment system allows ease of access and acknowledgement for all personnel, while ensuring no one slips through the cracks.  Using an automated reminder system for both staff and management helps ensure constant compliance and understanding of expectations and procedures.

Regular training is required for understanding of general topics such as Person Centered Planning and Cultural Diversity.  In addition to your general training program you should have training specific to your corporate compliance program and other specific policies and procedures.  Training and access to your compliance reporting system should be provided upon hire with instructions available throughout employment.

Reporting Mechanism – Anonymity

All personnel should feel comfortable bringing compliance deviations to the attention of the organization without fear of reprisal.  The 2014 National Business Ethics Survey of the U.S. Workforce determined that 60% of reported misconduct involved someone with managerial authority. More than 20% who reported misconduct said they experienced retaliation in return. A compliance reporting system that allows individuals to report anonymously provides several benefits.  Personnel are more likely to report suspected deviations and they are more likely to report sooner.  This allows the compliance officers, ethics committee and others to investigate and resolve compliance issues immediately.  The sooner compliance issues are resolved and corrective action taken, the less likely the deviation will continue or repeat.

The ideal compliance reporting system allows a compliance officer to respond to the complainant while allowing them to maintain their anonymity.  The challenge is segregating confidential, public and complainant information regarding the investigation. The secure, Online Corporate Compliance Reporting System provided by Accreditation Now, provides exactly that type of system.

Policy and Procedure Reviews

CARF® standards, and general good practice, requires regular review of your policies, procedures and other documents. The document management system provided through Accreditation Now provides the following:

  1. Receive email review reminders.
  2. Easily access documents from any location.
  3. Share with desired team members.
  4. Create an organized review summary.
  5. Protect your documents against catastrophic loss.


Creating a solid and effective compliance system goes beyond accreditation mandates. It can save your organization from costly legal issues in the future.  Your compliance system is critical in building a reputation that attracts qualified candidates for employment and produces more satisfied and productive employees.  Your public image is a direct reflection of how compliance issues are handled in your organization.  Accreditation Now offers many tools to assist in creating a complete compliance program.


This content provided by: Accreditation Now, Inc.