Policy AD-710 Document Retention and Destruction Policy 2021-07-16

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Policy Title: Document Retention and Destruction
Policy Number: AD-710	Policy Owner: Corporate Compliance Officer		Effective Date: 7/16/21
Attachment(s): Attachment A: Document Retention Schedule		Original/ Reviewed Date(s): 7/26/04, 12/16/08, 3/24/14, 4/28/15, 3/1/16, 7/7/2016, 1/9/18, 4/30/21, 7/16/21
Policy Executive: Chief Operating Officer (COO)	Policy Executive Signature:		Approval Date: 7/16/21
Board Representative: N/A	Board Representative Signature:		Approval Date:

Purpose

This policy provides the rules for record retention and destruction applicable to paper and electronic documents of Westside Family Healthcare, Inc. (Westside).

The policy also supports good governance practices and reflects Westside’s commitment to accountability and transparency, as well as its adherence to applicable laws relating to preservation and confidentiality of records and protection of employee and patient rights, including the Sarbanes-Oxley Act, Internal Revenue Code, the Civil Rights Act, HIPAA, other federal statutes, and Delaware Code.

Policy

Westside retains and maintains documents, as defined below, in their original form in accordance with time periods specified by law and/or based on best practices, as established in the attached schedule. Westside adheres to a regular business practice of document destruction, conducted when documents listed on the schedule reach their retention limit. All individuals covered by this policy are aware of their responsibilities with regard to document retention and destruction, including their legal obligation not to destroy, delete, or modify in any way documents related to a current or potential legal proceeding, as defined below.

Scope

This policy covers actions by all Westside Family Healthcare employees, volunteers, board members, and third parties in connection with the retention and destruction of Westside documents.

Definitions

Documents – Written information recorded on paper or in an electronic format. Electronic documents include but are not limited to those created via Microsoft Office or Adobe Acrobat as well as email messages and attachments, all of which may be stored on a computer, a server, the cloud, or by other electronic device or means.

Legal Proceeding – Any investigation, civil or criminal litigation, official proceeding, or any proper administration of any matter within the jurisdiction of any department or agency of the United States or of any state or local government.

Procedures

Document Retention

1. Westside is committed to compliance with legal requirements relating to document integrity, document retention, document destruction, and privacy.
2. Where legal requirements do not dictate a retention time, Westside follows best practices in determining appropriate retention procedures for its documents.
3. For some types of documents, Westside may choose to establish retention times that are longer than legally required, based on organizational needs and preferences.
4. Westside retains documents as necessary to comply with law and as needed for operations, but will seek to retain them no longer than as needed for such purposes.
5. Documents described in Attachment A: Document Retention Schedule below are maintained by the Human Resources, Administrative, Finance, and Health Information Management Departments and/or other appropriate parties for the time periods indicated.
6. If a document is not specifically described in the attached schedule, individuals seeking guidance should contact the Policy Owner identified above.
7. Retention of a document, whether or not identified in the attached schedule, should be determined primarily by application of the general principles of this policy and the specific requirements below relating to litigation-relevant materials.

Legal Proceedings

1. No documents will be destroyed or deleted if pertinent to any ongoing or anticipated government investigation or proceeding or private litigation.
2. Westside will not alter, destroy, delete, mutilate, conceal, cover up, falsify, or make a false entry in a record, or attempt to do so, with the intent to impair the record’s integrity or availability for use in a legal proceeding, as defined above, or impede, obstruct, or influence a legal proceeding.
  1. Violations of the relevant provisions in the Sarbanes-Oxley Act are punishable by fines or imprisonment up to 20 years.
3. If Westside learns of, or reasonably anticipates, a claim that may give rise to a legal proceeding, it will take appropriate actions, including cessation of destruction of records, to ensure safeguarding of records relevant to the legal proceeding.

Document Destruction and Deletion

1. All documents will be deleted from all individual computers, databases, networks, and back-up storage no earlier than the end of the periods described in Attachment A.
2. When the retention period for a document has been reached, the Director in charge of the department, working with the Director of Clinical Information Technology and the Director of Information Security and Technology/HIPAA Security Officer as necessary, will take the necessary steps to remove, destroy, or delete the document.
3. Confidential documents, including but not limited to medical records and employee records, will be shredded or otherwise destroyed in a manner that will preserve the confidentiality of their contents, in consultation with the Director of Site Operations/HIPAA Privacy Officer as necessary.
4. Processes for destruction and deletion are established and overseen by the Director of Site Operations/HIPAA Privacy Officer for paper documents and the Director of Information Security and Technology/HIPAA Security Officer for electronic documents.

Retention of Medical Records

1. Westside retains its medical records according to the attached schedule and recognizes the particular responsibility it has to its patients to ensure that its retention policies allow for records to be provided, as requested or needed, in accordance with law and regulation.
  1. The retention time of a medical record is determined by its use and Westside policies (this and others, as relevant), in accordance with law and regulation.
  2. Original medical records are not released unless the organization is responding to law and regulation. If original copies must be released, copies shall be made and retained.
2. Retention of medical records supports meeting federal and state legal requirements for prompt production of medical records, when requested by a current or former patient.
3. Retention of medical records supports meeting federal and state legal requirements related to transfer of and access to patient medical records due to a change of physician.

Oversight and Authority

1. The Compliance and Risk Management Committee will assess organizational compliance with this policy annually, confirming that appropriate documents are being retained and reviewing the destruction and deletion of documents for which the retention limit has been reached.
2. Exceptions to these rules and terms for retention may be granted only by the President & Chief Executive Officer or Chair of the Board.

References

IRS Compliance Guide for 501(c)(3) Public Charities. https://www.irs.gov/pub/irs-pdf/p4221pc.pdf

Document Retention Policies for Nonprofits, National Council of Nonprofits. https://www.councilofnonprofits.org/tools-resources/document-retention-policies-nonprofits

Sarbanes-Oxley Act, Sections 802 and 1102, The Sarbanes-Oxley Act and Implications for Nonprofit Organizations (Sarbanes-Oxley Act), July 30, 2002. https://www.congress.gov/107/plaws/publ204/PLAW-107publ204.pdf

Non-Profits and Sarbanes-Oxley, American Bar Association (ABA). https://www.americanbar.org/groups/center-pro-bono/resources/program-management/nonprofits_sarbanes_oxley/

Title VII of the Civil Rights Act of 1964 and other state and federal employment laws

Delaware Code, 10 Del. C. § 3926. Production of records, jurisdiction. https://delcode.delaware.gov/title10/c039/index.html

Delaware Code, 24 Del. C. § 1761. Physician discontinuing business or leaving the State; death of a physician; change of physician and transfer of patient records; patient access to records. https://delcode.delaware.gov/title24/c017/sc05/index.html

Relevant Standard from The Joint Commission (TJC): RC.01.05.01: The organization retains its clinical records. The Joint Commission (TJC). Leadership (LD) Comprehensive Accreditation Manual for Ambulatory Health Care (CAMAC), January 1, 2021.

ATTACHMENT A: DOCUMENT RETENTION SCHEDULE

RETAIN PERMANENTLY
Financial Records	Audited annual financial statements Annual auditors’ reports Attorney contingent liability letters Legal opinions Cash books Chart of accounts General and private ledgers Insurance policies, records and claims Journals Canceled checks, important
Governance Records	Annual reports Articles of incorporation Bylaws Charter and amendments Corporate resolutions Governing board and board committee minutes Other organizational documents
Intellectual Property Records	Copyright and trademark registrations Samples of protected works
Real Property Records	Assessments Blueprints and plans Deeds Depreciation reserves Depreciation schedules Licenses Mortgages Opinions Property appraisals Real estate sales agreements Rights of way Title abstracts
Tax Records	Filed state and federal tax returns, reports and supporting records IRS tax exemption determination letter and related correspondence IRS rulings IRS or other government audit records ERISA and retirement reports Payroll tax returns
RETAIN FOR THIRTY (30) YEARS
Certain Medical Records	Medical records of any employee exposed to toxic substances and harmful agents while on the job
RETAIN FOR TEN (10) YEARS
Medical Records	Patients’ medical records (from date of last appointment)
Government Relations Records	State and federal lobbying Political contribution reports Other relevant supporting records
Legal Proceedings Files	Claims and litigation files
Billing Records	Bills and correspondence Explanations of benefits Evidence of payment Medicare and Medicaid claims
Accountable Care Organization (ACO)-Related Documents	Documentation of quality performance measures for the ACO Shared savings distributions and other financial arrangements related to ACO activities
RETAIN FOR SEVEN (7) YEARS
Accident-Related Records	Accident reports and claims
Accounting Records	Accounts payable ledgers and schedules Accounts receivable ledgers and schedules Bank statements Budgets Canceled checks of a routine nature Depreciation schedules Documents evidencing terms, restrictions or conditions on gifts (from date when funds are expended) Expense analyses and distribution schedules Inventories Invoices from vendors Notes receivable ledgers and schedules Purchase orders Sales records Scrap and salvage records Stock and bond certificates, canceled Subsidiary ledgers Tax bills, receipts and statements Time books Trial balances Vouchers for payments to vendors and employees Voucher registers and schedules
RETAIN FOR SIX (6) YEARS
Employee Benefits Records	Employee benefits records Employee benefits summary plan descriptions
ERISA Filings	ERISA filings ERISA supporting documents
Patient Complaints Records	Patient complaints Responses to patient complaints
Performance Improvement Documents	Performance improvement reports Performance Improvement plans
HIPAA Privacy Documents	HIPAA privacy policies and procedures HIPAA privacy practices notices HIPAA disposition of complaints Other actions, activities, and designations that the HIPAA Privacy Rule requires to be documented
RETAIN FOR FIVE (5) YEARS
OSHA Reporting and Records	Annual reports of occupational injuries and illnesses (from the end of the calendar year covered by the records) Occupational injuries and illnesses records where medical attention (not including first aid) resulted (from date of injury or illness) (OSHA Form No. 200) Supplemental records for each occupational injury or illness (OSHA Form No. 101) (from end of calendar year covered by the records)
RETAIN FOR FOUR (4) YEARS
Contracts	Contracts and related documents (from date of expiration or termination of contract), including: Leases Software license agreements Vendor, hotel and service agreements Independent contractor agreements Consultant agreements
Personnel Files	Personnel files of terminated employees (from date of termination of employment)
RETAIN FOR THREE (3) YEARS
Credentialing Files	Credentialing files (from death or termination of employment of provider)
	I-9 Employment Verification Forms for terminated employees (from date of termination)
Wage-Related Documents	Wage rate tables Salary scales Any other wage-related documents
Employee Files	Records that include the following identifying employee information: Name Address Date of birth Social Security Number Occupation Rate or basis of pay and terms of compensation Daily and weekly hours worked per pay period Additions to or deductions from wages Total compensation earned and paid each week
FMLA records and documents	All records relating to FMLA leave requirements All documents describing FMLA notices
Organizational and Human Resources Documents	Organizational charts Job descriptions Employee handbooks Employee newsletters
Medical Operations Records and Documents	Medical/Dental biohazard waste manifests Medical operations records not listed elsewhere in this policy, including: Point of Care Quality Checks, Emergency Response Cart Checks, Eyewash Station Checks, etc.
RETAIN FOR TWO (2) YEARS
EEO Reports	EEO-1 Employer Information Reports (from date filed)
RETAIN FOR ONE (1) YEAR
Assorted documents and records, including: Job Applicant and Job Order documents Electronic records, documents, and files Deposit Slips	Applications, résumés and related documents of unsuccessful job applicants (from date of selection of successful applicant) Job orders submitted to employment agencies (from date of job order) All other electronic records, documents and files, including: Correspondence files Publications Survey information Duplicate deposit slips

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