Retention of Records
Records are maintained to provide complete and accurate information about consumers for continuity of care, treatment and training. The record will contain sufficient information to identify the consumer clearly, justify the diagnosis, reflect assessment, establish a plan with a statement of goals and objectives for implementation of training and treatment, and accurately document results of implementation. In addition to complete and accurate documentation, the record will be readily accessible and systematically organized to facilitate retrieving and compiling information. It shall be properly secured to insure confidentiality for the person as well as their family.
Types of Records
- Active Records - records of consumers who are actively receiving services through MDCBDSN, the SCDDSN or a specific provider.
- Inactive Records - records of consumers who have been deemed to be ineligible for services, or were receiving services and have since been discharged out of MDSBDSN, or to another provider within MDCBDSN, SCDDSN's provider network, or are deceased.
Types of Documents
- Vital documents - information required by SCDDSN standards or other regulatory standards to be kept in the record until the end of the designated retention period (demographic data, medical and psychological evaluations, social history, etc.).
- Non-vital documents - supporting information that may be discarded when no longer needed for reference (activity schedule, clothing inventories, SRS forms, training programs, housing surveys and inspections, etc.).
Detailed requirements are documented in the agency's retention schedules and vital documents list for consumer records. Refer to attached retention schedules and vital documents lists as indicated below.
- Residential Records - examples are Community Training Homes (CTH), Supervised Living Programs (SLP) and Community Residential Care Facilities (CRCF).
- Day Programs - examples are Supported Employment, Child Care Development, Adult Development, Sheltered Workshop, Day Care.
- Family Support / Service Coordination - examples are Service Coordination, Respite, Early Intervention.
Consumer Records Management
MDCBDSN assigns responsibility to the Family Support Administrator, Residential Administrator and Day Program Administrator to supervise consumer's records in their respective areas. Our records managers designated will be held accountable for maintaining the records, and given the authority to control their use.
The original records for anyone to be evaluated for services or for persons receiving services will be maintained by MDSBDSN and shall be available for review by all authorized persons. Secured records should be taken to meetings held in places other than MDCBDSN's location, so as to reduce the possibility of loss or violation of security and confidentiality. All original consumer records will be maintained by MDCBDSN until appropriate case transfer is necessary.
A person's records should only be removed or destroyed in accordance with this policy. Failure to comply with this policy could result in disciplinary and/or legal action.
Confidentiality of Information and Record
South Carolina law declares that all records pertaining to the identity of any person whose condition or treatment has been studied by the Department of Disabilities and Special Needs are confidential. This disclosure of client information and records is governed by SC Code Ann. 44-20-340- (Law.Co-op. 1976). This section reads as follows:
44-20-340 Confidentiality of information and records
A person, hospital, or other organization may provide information, interview, reports, statements, written memoranda, documents, or other data related to the condition and treatment of a client or applicant to the department, and no liability for damages or other relief arises against the person, hospital, or organization for providing the information or material.
All records pertaining to the identity of a person whose condition or treatment has been studied by the department are confidential and privileged information. However, upon the written request of the client, the client's or applicant's parent with legal custody, legal guardian, or spouse with the written permission of the client's or applicant or under subpoena by court of law, the department may furnish pertinent records in its possession to appropriate parties.
The MDCBDSN will also meet record requirements as mandated by HIPAA laws.
Authorization for Access to Records
- Record Content - Information contained in the consumer record is confidential and shall be disclosed only to authorized persons with the consumer, parent, or guardian's consent except as otherwise stipulated in this document.
- Responding to Requests for Information - Verbal requests for information shall be discouraged and limited to emergency situations in which professionals or health care facilities treating the consumer request immediate information for continuity of care. If there is any doubt as to the identity of the caller, a call-back system shall be used to confirm the identity of the professional or agency requesting the information. The consumer's file will be documented to define the circumstances of the release including what documents were released to who and the signature of the person authorizing the release.
- Release of Information - Unless required by law, the information shall not be released without a written authorization for release of information, signed by the consumer or the consumer's legal representative. Information from the record will be available without the consumer's written authorization upon transfer to another agency, when required by law under a third party payment contract, and to those with a legitimate need to see the information.
- Access Rights
- The Consumer - The consumer's record shall be made available for inspection, if requested. The consumer will be encouraged to review the record in the presence of an attending physician or representative of the agency. If the consumer has been declared legally incompetent, the consumer's legal representative may exercise the above right on the individuals' behalf. The consumer or a legal representative may receive a copy of the record within a reasonable time after the request, at the consumer's expense.
- Consumer's Family - The philosophy of the State of South Carolina and the SCDDSN as well as the MDCBDSN is that parental rights do not terminate when a person is admitted to, or receives services from, any of the agency's authorized service providers (Statute 44-21-20). Therefore, the parents have access to the records of their son(s) or daughter(s) as specified by state law.
- Health Care and Agency Personnel - Access to records will be limited to personnel with a legitimate need for the information. Information necessary for continuity of care will be available to health care and professional staff. Consumer records used for committee and research purposes shall have the identity of the consumer protected. Authorizations by the consumer to use this information is not required.
- Other Health Care Agencies / Physicians Caring for the Consumer - When a consumer is transferred to the care of another physician or health agency, information shall accompany the consumer to assure continuity of care. Authorization by the consumer to release this information is not required.
- Other Health Care Providers Not Caring for the Consumer - The consumer's authorization or that of a person legally authorized to act on his or her behalf must be obtained to release information to hospitals, physicians, and other health care facilities.
- Long Term Care Surveying / Accrediting Agencies - Government and private accreditation agencies, such as First Health, SCDDSN, DHEC, CMS, etc. involved in long term care may have access to the consumer's records without authorization, if such review relates to licensure/certification requirements. For example, authorization is not required in order for Medicare or Medicaid representatives to review records of Medicare or Medicaid recipients.
- Government Agencies - Confidential information may not be released to government agencies without valid authorization from the consumer or a legally authorized person, unless required by subpoena, federal law, or state stature, exempt as mentioned in "F" above.
- Insurance Companies - The consumer's written authorization or that of a person legally authorized to act on his or her behalf must be obtained before any information will be released to an insurance company, unless otherwise specified by third-party payment contract.
- Attorneys - The consumer's authorization or that of a legally authorized person must be obtained to release information to attorneys, even if the consumer has filed a lawsuit. The agency's legal representative may obtain information to protect the interest of the agency in liability or compensation cases.
- Law Enforcement Officials - Confidential information may not be released to law enforcement officials without valid authorization from the consumer or a legally authorized person, unless by state stature or in a response to a valid subpoena.
- Subpoenas - A "subpoena duces tecum" requires a witness to produce the consumer's record as outlined in the subpoena. When the courts subpoena records or the agency, the appropriate or designated Administrator shall take the record to the court or a person assigned by the Administrator. An exact photocopy of the original record (along with the original) shall be taken to court. If the record is to remain in the courts, the court shall be asked to accept the photocopy of the record and shall be requested to return this copy to the agency when the case is closed. A receipt of the photocopy record will be obtained from the court.
- News Media - Confidential information may not be released to the news media without the consumer's or legal representative's authorization. Consumers do not waive rights of privacy by admittance to the agency.
- Authorization Form - A valid authorization form to release information should contain at least the following information:
- Name of person, agency or organization to which the information is to be released.
- The specific information to be disclosed.
- The purpose of the disclosure.
- The date the consent was signed and signature of the individuals witnessing the consent.
- A notice that the consent is valid only for a specific period of time.
If the consumer has reached the age of maturity and is mentally competent or is an emancipated competent minor, the consumer should sign the authorization form.
An unaltered photocopy of the original authorization form may be accepted in lieu of the original. The original authorization form or a valid photocopy of the original will be filed in the record.
Storage, Filing, and Retrieval
All individual records shall be kept in a secure manner and stored so that information contained in the records is kept confidential. Active records should be kept at a location that allows easy access to MDCBDSN staff, SCDDSN staff, and other licensing or oversight agencies. Inactive records should be stored in a central location by MDCBDSN until the end of the retention period. Central locations are as follows:
- Dillon Center - Archive Financial Files
- Dillon Center - Archive Personnel Files
- Marion Center - Archive Service Coordination Files
- Dillon Center - Archive Early Intervention Files
- MLK CTH Garage - Archive Residential Files
Annual Review and Purging
Active records are reviewed periodically and all superseded documents and those no longer needed for references should be moved from working files to the holding files at one of the central sites mentioned above.
Inactive records are reviewed periodically and maintained at MDCBDSN central storage sites, mentioned above, according to the current retention and disposition schedules.
If any litigation, claim, or other action involving the records has been initiated prior to the expiration of the above period, MDCBDSN will retain the records until completion of the action and resolution of all issues that arise from it or until the end of the retention period, whichever is later.
Records Retention and Disposition
The retention and disposition of individual records are established with the Division of Archives and Records Management through the records management section of the Information Resource Management (IRM) division at the Central Office of DDSN. The retention periods are established based on the requirements of licensing agencies such as Department of Health and Environmental Control (DHEC), Health and Human Services Finance Commission (HHSFC), DDSN, and existing legal requirements. The goal of the retention and disposition schedules is to ensure that records a retained long enough to meet all requirements for audit and reference. Strict adherence to retention and disposition schedules is necessary to good records management and will be monitored by SCDDSN's internal audit department.
Community Residential Care Facilities must retain all medical records for 10 years after the consumer's death or discharge; or the end of the provider's contract period with SCDDSN. In addition, Community Training Homes, Supervised Living Programs, Early Intervention and Service Coordination vital records are retained for 6 years after the consumer's death or discharge; or the end of the provider's contract with SCDDSN. Financial records will be maintained for at least 7 years.
Board / Provider has a system to ensure the security and confidentiality of records. Destruction of records will meet HIPAA and State confidentiality requirements.
When a discharge occurs, a copy of the vital documents and discharge summary will be sent to the receiving facility. The sending facility will place the original vital document and the discharge summary together with its vital documents in storage and comply with the retention schedule.