BHDD directive 368-01-DD: Records retention of individual service records

Document Information

Reference Number: 368-01-DD

Title of Document: Records Retention of Individual Service Records

Date of Issue: February 1, 1995

Date of Last Revision: July 15, 2021

Effective Date: July 15, 2021 (REVISED)

Applicability: DDSN Operated Residential Programs, DDSN Regional Centers, DSN Boards, Contracted Service Providers, and DDSN Eligibility Division

I. PURPOSE

This directive establishes the agency's policy regarding the management of records relating to persons receiving services through the South Carolina Department of Disabilities and Special Needs (DDSN) and its network of service providers. This directive does not apply to any of DDSN's internal records to include operational or financial records, which are addressed in a separate DDSN Records Management Manual.

II. POLICY

Individual service records are maintained to provide complete and accurate information and support continuity of care, treatment, and training. The record will contain sufficient information to clearly identify the person, justify the diagnosis, reflect assessment of needs/goals, and establish a plan for implementation of care, including training, treatment, and/or community services/supports, as well as accurately document results of implementing the plan of care.

In addition to complete and accurate documentation, the record will be readily accessible and systematically organized to facilitate retrieving and compiling information. It will be properly secured to ensure confidentiality for the person.

III. DEFINITIONS

A. Types of Records

i) Active records: Records of persons actively receiving services through DDSN or a provider in DDSN's network.

ii) Inactive records: Records of persons deemed ineligible for DDSN services or are no longer receiving services from DDSN or its provider network for any reason (e.g., death, relocation, etc.).

B. Types of Documents

i) Vital documents: Documents required by DDSN standards, other regulatory standards, or by law to be kept in the record until the end of the designated retention period or until any legal action(s) is completed, whichever is longer. Vital documents may include, but not limited to, the Service Agreement, DDSN eligibility determination, contact/service/progress notes, service/treatment/program/support plans, Medical Necessity Statements, documentation of service delivery, service authorizations, signed consent forms, Level of Care Determination forms, and signed Freedom of Choice forms.

Vital documents among DDSN service delivery records most often fall into the following three categories:

(a) Fiscal: These documents hold information supporting the expenditure of funds. These funds may be public funds or private funds, including those belonging to the individual.

(b) Legal: These documents provide evidence addressing the legal rights of the person receiving services, obligations of DDSN to the person, or compliance with relevant laws and regulations.

(c) Health: These documents record the current health status of the individual, care and treatment currently received or needed, and significant health history.

ii) Non-vital documents: These are supporting information that can be destroyed when no longer needed. Non-vital documents may include, but are not limited to, activity schedules, clothing inventories, training programs, and copies of vital documents known as convenience copies made for short term use.

C. Types of Record Categories

i) Intermediate Care Facility for individuals with Intellectual Disabilities (ICF/IID).

ii) Non-ICF/IID which include the following sub-categories:

(a) Residential Habilitation Services provided in models such as Community Training Homes (CTH), Supervised Living Programs (SLP), and Community Residential Care Facilities (CRCF).

(b) Employment/Day Services include Day Activity, Career Preparation, Community Services, Support Center, Employment Services - Group, and Employment Services - Individual.

IV. RECORDS MANAGEMENT AND ACCOUNTABILITY

A. Responsibility for establishing management and accountability requirements for the records of DDSN and its provider network is assigned to the DDSN Records Officer, which will be the DDSN's Director of Information Technology.

B. Each service provider will designate a Records Officer for its respective agency/company and assign this person the responsibility for management and accountability for both paper and electronic records. This Records Officer will be held accountable for maintaining the records according to DDSN policy, as well as be given the authority to manage the records and their use.

C. Original records for anyone evaluated or receiving services will be maintained by the service provider and must be available during normal business hours for review by all authorized persons. If electronic documents are required for review/audit, access to the information must be provided. Copies of records, not original records or sole copy records, should be used when those records are required in places other than the service provider's locations to reduce the possibility of loss.

D. Service Providers must ensure adequate security safeguards are in place for all work settings to prevent loss or unintended destruction of the contents of records.

E. Because records include confidential protected health information and/or confidential educational documents, any active or inactive record that cannot be made available in its entirety as stated above, will be considered a lost record and therefore represents an unauthorized disclosure of information. Should this happen, the provider must:

i) Report the loss of the record or document immediately to the service provider's HIPAA Privacy Officer and the designated Records Officer. This person will then immediately telephone or email a brief report of the loss to DDSN's Privacy Officer. This brief report will then be followed by a detailed written report of the loss to the DDSN Privacy Officer. This written report should use Attachment A to this directive titled, "Record/Document Loss Report" or the report should provide the same content. Together, these Privacy Officers are responsible for communication about and coordination of an appropriate response to the loss of the record. If the lost record is a Medicaid recipient's active record or inactive record for which the required record retention for Medicaid records has not been exceeded, DDSN will report the loss to South Carolina Department of Health and Human Services (DHHS).

ii) Notify the individual/legal guardian upon direction of DDSN. Documentation of this notification must be retained and be available in the individual's remaining or reconstructed case record.

F. Records should only be removed or destroyed in accordance with this directive. Failure to fully comply with this directive could result in disciplinary and/or legal action.

V. RECORD STORAGE

All records will be securely stored to ensure information contained in the records is kept confidential and safe from damage or destruction. Electronic data must be protected by encryption, specifically including "data at rest" encryption, to meet Health Insurance Portability and Accountability Act (HIPAA) requirements.

Active records should be kept at a location which allows ready access by agency staff, DDSN, and other entities with a legal right to access. Inactive records should be stored in a central location by the service provider until the end of the retention period. Inactive records may be stored using suitable electronic media approved by DDSN to facilitate their security and/or to reduce required storage space. To seek approval on electronic media, please contact the DDSN Records Officer by emailing records@ddsn.sc.gov.

VI. ANNUAL REVIEW AND PURGING

Active records should be reviewed annually as a quality control to ensure all inactive files have been moved to a central inactive file location. Inactive records will be reviewed annually and destroyed according to the current retention and disposition schedules. Any non-vital documents not previously destroyed should be destroyed as well. Any records destroyed should be reported to the service provider's Records Officer.

VII. RECORDS RETENTION AND DISPOSITION

All individual service records, to include ICF/IID and all Non-ICF/IID services (i.e., CRCF, Residential Habilitation, Employment, Day Services, and State Funded Family Support Services) record retention, review period, disposition, and transfer information are contained in Attachment B.

The retention and disposition schedules of service delivery records are established in conjunction with the SC Department of Archives and History through the DDSN Information Technology Department. The retention and disposition schedules for electronic service records and paper records are the same.

As part of this process of establishing retention and disposition schedules, a records inventory determines which service delivery records are considered to be vital documents. Retention periods are based on the requirements of regulatory and relevant state and federal law. The goal of the retention and disposition schedules is to ensure that records are retained long enough to meet all the requirements for audit and reference, yet be disposed of in a timely manner to reduce document handling and storage. Strict adherence to retention and disposition schedules is necessary for appropriate records management.

VIII. TEFRA MEDICAID RECORDS

DDSN routinely receives requests from the South Carolina Department of Health and Human Services (SCDHHS) to make an ICF/IID Level of Care (LOC) determination on behalf of persons applying for Medicaid eligibility under the category known as TEFRA (Tax Equity and Fiscal Responsibility Act of 1982). These persons may or may not have applied or be eligible for DDSN services.

These records are to be managed in accordance with this directive with one exception. The one exception pertains to if an individual does not meet the required criteria for ICF/IID LOC and is not DDSN eligible and is not applying for DDSN eligibility. For these circumstances, then copies of all records, documents, or other information obtained to make the LOC determination must be retained for one year after the LOC decision by the DDSN Eligibility Division or until any appeal of a Medicaid eligibility denial has ended, whichever is later.

When this retention period has ended, these records must be destroyed in a manner such that the personal health information is unreadable.

Attachments

To access the following attachments, please see the agency website page "Current Directives" at: https://ddsn.sc.gov/providers/ddsn-directives-standards-and-manuals/current-directives

Attachment A: Record/Document Loss Report
Attachment B: Records Retention, Review Period, Disposition, and Transfer Requirements

Note: Attachments A and B (the detailed Record/Document Loss Report form and the Records Retention, Review Period, Disposition, and Transfer Requirements schedule) are maintained separately on the DDSN website at the link above and were not included in the source text provided for this entry. Providers should consult the linked attachments directly for the specific retention periods applicable to each record category.