POLICY AND PROCEDURE
House of New Hope
POLICY: CRM-805
TITLE:Maintenance of Client Files
EFFECTIVE DATE: January 1, 2008AUTHORIZED BY: Board of Trustees
REVISION DATE: 4/17/2013, 2/2014
1.EXPUNGING RECORDS
a.HONH will assure information provided in the record meets expected standards of documentation, to include items dated, having client names, fully completed and signed by the author. Items containing unsummarized notes or incomplete forms should not be placed in a client file.
b.HONH clerical staff will be trained to review all records for unacceptable items. Files will be reviewed upon termination.
2.ARCHIVING RECORDS – STORAGE OF TERMINATED FILES
a.When a client is terminated from care/services, the file will be reviewed for any documentation that does not meet required standards, to expunge such material.
b.All treatment staff will be required to incorporate personal notes or documentation back into the record or to have such material shredded.
c.Closed files will be logged as to client name, date of birth, intake and termination date, location of record (site and cabinet location) and date eligible to be destroyed.
d.Records are to be maintained for seven (7) years from date of age of majority for foster care clients;
e.Records are to be maintained indefinitely for adoptive youth and families.
f.Records are to be maintained for seven (7) years from date of service termination for adult and adolescents receiving Alcohol and Other Drug Services and Mental Health services.
g.Annually, archived records will be checked to determine which files are eligible to be destroyed and appropriately disposed of.
h.Archived files will be maintained in a manila envelope and stored in file storage boxes or file cabinets in safe and secure areas.
i.Files will be stored according to year of termination, clearly designating client’s date of birth and name. Per each year, files should be ordered chronologically according to date of birth.
j.Any records maintained electronically will be maintained within the privacy safeguards needed to assure confidentiality of information. In addition, records will be stored in a manner that enables immediate retrieval of information as requested.
3.Records will be stored in accordance with Federal regulations (42 CFR Part 2) which states:
“This information has been disclosed pursuant to you from records protected by Federal confidentiality law rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client.”
If the records released include information of an HIV-related diagnosis or test result, the following statement applies:
This information has been disclosed to you from confidential records protected from disclosure by state law. You shall make no further disclosure of this information without the specific, written, and informed release of the individual to who it pertains, or as otherwise permitted by state law. A general authorization for the release of medical or other information is NOT sufficient for the purposes of the release of HIV test results or diagnoses.
4.DESTRUCTION OF CLIENT RECORDS
HONH acknowledges the importance of maintaining client confidentiality. Upon client records exceeding the required period of archival, records will be destroyed. (See Archiving Policy for time frames.) Method of destruction may include shredding all materials and/or contracting with an agency to destroy records through incineration or other appropriate means of destruction. Any contracted agency will be expected to meet all confidentiality requirements. Records will be maintained of any records that are destroyed. In the event that a legal process is initiated against the organization, destruction of records associated will be stopped until the legal process is finalized.
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