Healthcare Compliance Records Retention Schedulecitysecretary2.dallascityhall.com/pdf/records/retention/CP.pdfpractices, internal and external audit evaluations, and final outcomes.

Division Record Series

HIPAA Complaints

Compliance Complaints

HIPAA Investigations

Healthcare Compliance Records Retention Schedule

Records & Comments

Any individual complaints regarding HIPAA compliance and their outcomes, as well as any sanctions for violations of HIPAA requirements. Legal opinion and audits related to complaint. This includes complaints received by telephone, in-person, or via e-mail.

Any individual complaints regarding Federal Healthcare Program compliance and their outcomes, as well as any sanctions for violations. Legal opinion and audits related to complaint. This includes complaints received by telephone, in-person, or via e-mail.

Documentation related to HIPAA reports and investigations. Can include but not limited to audit reports of contracts that are HIP AA related, correspondences, postal and delivery services records, HIPAA training related records, HIP AA related litigation, ambulance transport report, dispatch report, CIS report, lost or stolen items containing PHI information and HIP AA related disciplinary and adverse action records (e.g. sanctions).

Note: HIPAA- 45 C.F.R. § 160.310(b); Part 4, Section 4-1: Fire and Emergency Medical Response Records

State Schedule Legal Requirement

HR4900-01 7 years

HR4900-02 10 years

PS 4450-02A 7 years

HR4900-01 7 years

Reference: HIPAA - 45CFR164.316; IDPAA- 45 C.F.R. § 160.310(b); Part 4, Section 4-1: Fire and Emergency Medical Response Records; False Claims Act (31USC3731); CMS MLN # SE1022 and 42 CFR § 422.504

HR 4900-01: 7 years; HR 4900-02: 10 years AC= After Closed, terminated, completed, expired, settled, AV= As long as Administratively Valuable, CE= Calendar-year End,

Exempt= Exempt from Destruction Request Requirement, FE= Fiscal-year End, GR= General Records Schedule, HR= Health Records Schedule, US= Until Superseded, PS= Records of Public Safety Agencies (Police, Fire, EMS, ME, etc.)

Revision Date: February 14, 2018 Page 1


Division Record Series Records & Comments State Schedule Legal Requirement

Compliance Investigations Documentation related to Compliance reports and investigations. Can include HR4900-02 but not limited to audit reports of EMS billing, contracts that are Compliance 10 years related, correspondences, postal and delivery services records, ambulance transport report, dispatch report, CIS report, Compliance training related records, Compliance related litigation, and Compliance related disciplinary and adverse action records (e.g. sanctions).

Note: False Claims Act (31USC3731); CMS MLN # SE1022 and 42 CFR § 422.504

HIPAA Audit Records- All documentation relating to Release of Medical Record process, HIP AA HR4900-0l Department copies and related productivity logs, HIPAA Performance Reports, HIPAA dashboard, 7 years work papers HIPAA risk assessments, HIPAA Privacy and Security Walk-throughs for

covered entities and selected departments that utilize HIP AA safeguarding practices, internal and external audit evaluations, and final outcomes.

Compliance Audit Records- Documentation relating to Compliance related productivity logs, Compliance HR4900-02 Department copies and Performance Reports, Compliance dashboard, Compliance billing related 10 years work papers reports, License Verification of EMS State License, OIG related screening and

supporting documents, internal and external audit evaluations, and final outcomes.

HIPAA Training Manuals and Training manuals, syllabuses, course outlines, attendance logs, signed HR4900-0l Educational Materials attestations, post-exam questions, post-exam scores, completion and non- 7 years

completion reports, and similar training aids used for in-house and/or vendor training programs.

Reference: HIPAA - 45CFR164.316; IDPAA- 45 C.F.R. § 160.310(b); Part 4, Section 4-1: Fire and Emergency Medical Response Records; False Claims Act (31USC3731); CMS MLN # SE1022 and 42 CFR § 422.504

HR 4900-01: 7 years retention and HR 4900-02: 10 years retention, AC::: After Closed, terminated, completed, expired, settled, AV::: As long as Administratively Valuable, CE::: Calendar-year End,

Exempt::: Exempt from Destruction Request Requirement, FE::: Fiscal-year End, GR::: General Records Schedule, HR::: Health Records Schedule, US::: Until Superseded, PS= Records of Public Safety Agencies (Police, Fire, EMS, ME, etc.)

Revision Date: February 14, 2018 Page2



Compliance Training Manuals and Training manuals, syllabuses, course outlines, attendance logs, signed HR4900-02 Educational Materials attestations, post-exam questions, post-exam scores, completion and non- 10 years

completion reports, and similar training aids used for in-house and/or vendor training programs.

HIPAA Minutes of Committee Minutes, handouts, attendance logs, and agendas of internal staff meetings. HR4900-01 Meetings Includes committee, other departments, and BAA associates. 7 years

Compliance Minutes of Committee Minutes, handouts, attendance logs, and agendas of internal staff meetings. HR4900-02 Meetings Includes committee, other departments, and BAA associates. 10 years

HIPAA Correspondence and Correspondence and internal memoranda pertaining to the formulation, HR4900-01 Internal Memoranda and planning, implementation, modification, or redefinition of the policies, 7 years Subject Files- Policy and programs, services, or projects of a local government, including Council Program Development Resolutions and internal correspondence and memoranda. May also include Includes informal legal subject files, which are collections of correspondence, memos and printed opinions materials on various individuals, activities and topics.

Note: Review before disposal; some documentation of this type may merit permanent or long-term retention for historical or legal reasons.

Reference: IDPAA- 45CFR164.316; IDPAA- 45 C.F.R. § 160.310(b); Part 4, Section 4-1: Fire and Emergency Medical Response Records; False Claims Act (31USC3731); CMS MLN # SE1022 and 42 CFR § 422.504

HR 4900-01: 7 years retention and HR 4900-02: 10 years retention, AC= After Closed, terminated, completed, expired, settled, AV= As long as Administratively Valuable, CE= Calendar-year End,





Compliance Correspondence and Correspondence and internal memoranda pertaining to the formulation, HR4900-02 Internal Memoranda and planning, implementation, modification, or redefinition of the policies, 10 years Subject Files- Policy and programs, services, or projects of a local government, including Council Program Development Resolutions and internal correspondence and memoranda. May also include Includes informal legal subject files, which are collections of correspondence, memos and printed opinions materials on various individuals, activities and topics.


Healthcare Correspondence and Correspondence and internal memoranda pertaining to the formulation, GR 1000-26A Compliance Internal Memoranda and planning, implementation, modification, or redefinition of the policies, 4 years

Subject Files- Policy and programs, services, or projects of a local government, including Council Program Development Resolutions and internal correspondence and memoranda. May also include Includes informal legal subject files, which are collections of correspondence, memos and printed opinions materials on various individuals, activities and topics.


Healthcare Legal Opinions Formal legal opinions rendered by counsel or the Attorney General for a local GR 1000-30 Compliance government, including any written requests for opinions, concerning the Permanent

governance and administration of a local government.

Note: Informal legal opinions use GR 1000-26A.

Healthcare Litigation Case Files- Litigation case files, including all cases to which a local government is a party GR 1000-31 Compliance Departmental copies unless the case file is of a type noted elsewhere in the schedules. AV after final decision

Reference: IDPAA- 45CFR164.316; HIP AA- 45 C.F.R. § 160.310(b); Part 4, Section 4-1: Fire and Emergency Medical Response Records; False Claims Act (31USC3731); CMS MLN # SE1022 and 42 CFR § 422.504



Revision Date: February 14, 2018 Page4



Healthcare Policy and Procedures Orders, directives, manuals, similar documents that establish and define the GR 1000-38 Compliance Documentation policies, procedures, research, guidance, rules, and regulations governing AC+ 5 years

operations or activities of a federal or local government as a whole or any of its departments, programs, services, or projects.

Note: Review before disposal. Some documentation of this type may merit permanent or long-term retention for historical or legal reasons.

Healthcare Audit Records- Annual or biennial or other periodic audits of a department, program, fund. GR 1025-0lE Compliance Department copies and Working papers, summaries, and similar records created for the purposes of 3 years after all

work papers conducting an audit. Individual authorizations and designation of personal questions have been representative (including all supporting documentation for authorization). Both resolved Internal and External Auditors. Includes Internal Control Reports from Internal Control Task Force.

Healthcare Contracts, Leases, and Contracts, leases, and agreements, including reports, correspondence, and GR 1000-25 Compliance Agreements- Contract similar records related to their negotiation, administration, renewal, or AC+ 4 years

Administration termination. Includes Business Associate Agreements (BAA), Administrative Actions, bid specifications and proposal received from winning vendor.

Reference: IDPAA- 45CFR164.316; IDPAA· 45 C.F.R. § 160.310(b); Part 4, Section 4-1: Fire and Emergency Medical Response Records; False Claims Act (31USC3731); CMS MLN # SE1022 and 42 CFR § 422.504


Exempt= Exempt from Destruction Request Requirement, FE= Fiscal-year End, GR= General Records Schedule, HR= Health Records Schedule,

Revision Date: February 14, 2018 US= Until Superseded, PS= Records of Public Safety Agencies (Police, Fire, EMS, ME, etc.)

Pages



Healthcare Budget Documentation- Working papers created exclusively for the preparation of budgets, including GR 1025-04C Compliance Department copies and budget requests, justification statements and similar documents. Budget change 2 years

work papers documentation, including the line item or contingency/reserve fund transfers and supplemental budget requests. Encumbrance and expenditure reports. Includes operating budget, equipment, programming, grant, submissions; Long range Plan; adjustment requests; preparatory work and supporting documentation; projections and estimates; financial reports; journal vouchers; manual warrants; expense budget lines.

Note: Official record copy of Annual Budget filed in City Secretary's Office (permanent retention)

Healthcare Financial Reports and Monthly, bi-monthly, quarterly or semi-annual financial reports or statements GR 1025-07A Compliance budget documentation- on the accounts, funds, or projects of a local government create either for FE+ 3 years

Department copies and internal use or for submission to state agencies as may be required by law or work papers regulation, except reports of similar types noted in this or other commission

schedules. Includes working papers created exclusively for the preparation of the budgets, such as budget requests, justification statements, and similar documents; operating budget, equipment, programming, and grant submissions; Long Range Plans; adjustment requests; budget preparatory work and supporting documentation; projections and estimates; financial reports; journal vouchers; manual warrants; expense budget lines; cost allocation and distribution records; annual transaction summaries; and depreciation schedules.

Reference: IDPAA- 45CFR164.316; IDPAA- 45 C.F.R. § 160.310(b); Part 4, Section 4-1: Fire and Emergency Medical Response Records; False Claims Act (31USC3731); CMS MLN # SE1022 and 42 CFR § 422.504






Healthcare Ledgers, Journals, and General ledger showing receipts and expenditures from all accounts and funds GR 1025-30 Compliance Entry Documentation- of a local government, subsidiary ledgers, receipts, disbursements, general, or FE+ 5 years

Department copies subsidiary journals, journal vouchers and entries or similar posting control forms including supporting documents, amendments correspondence, journal entries, and auditor adjustments.

Healthcare Employee Selection Notes of interviews with candidates; resume; applicant rosters; eligibility lists; GR 1050-11 Compliance Records- candidates not offers of employment letters; and similar records documenting the filling of a 2 years from creation

hired/appointed vacant position. (or receipt) of the record or the personnel action

Note: Records of candidates who are hired or appointed become part of involved, whichever is the employee's Personnel file. later.

Healthcare Disciplinary and Adverse Records created by personnel and supervisory officers in considering or GR 1050-07 Compliance Action Records reconsidering on appeal, an adverse reaction (e.g. demotion, probation, 2 years after case

termination, suspension, leave without pay against an employee, including, as closed or action taken applicable, witness and employee statements, interview reports, exhibits, reports of findings and decisions and judgments).

Healthcare Personnel Files - Records about an employee. Applications, resume, awards, commendations, GR 1050-12D Compliance Employee Service certifications, licenses, conflict of interest forms, P-2 forms, training records, Date of Separation

Records etc. Documents used to create or change information in the personnel record of from the city + 5 years individual employees concerning hiring, termination, transfer, pay grade, position or job title, leave of absence, name changes and similar personnel actions except those listed elsewhere in this schedule.

Note: If employee transfers to another city department send file to the new department.

Healthcare Payroll Records Payroll register, payroll adjustment records, leave records including requests GR 1050-52 Compliance and authorization to use leave. Timesheets. FE+ 3 years

Reference: HIPAA- 45CFR164.316; HIPAA- 45 C.F.R. § 160.310(b); Part 4, Section 4-1: Fire and Emergency Medical Response Records; False Claims Act (31USC3731); CMS MLN # SE1022 and 42 CFR § 422.504






Healthcare Training Manuals and Training manuals, syllabuses, course outlines, attendance logs, signed GR 1050-28C Compliance Educational Materials attestations, CEUs, certifications, and similar training aids used. US, expired, or

discontinued +2 years

Preparedby:~~O\~ v~/!5/;;o1r/ Priscilla Villanueva Date Records Liaison Officer Healthcare Compliance

Reviewed by: ~~ )) ~ ~ -( S" - { )$7

Lois A. Dillard, CRM Records Management Officer City Secretary's Office

Date Approvedby:~rfi~ ~~{~3

Chief of Ethics and Compliance Ethics and Compliance

Reference: HIPAA- 45CFR164.316; IDPAA- 45 C.F.R. § 160.310(b); Part 4, Section 4-1: Fire and Emergency Medical Response Records; False Claims Act (31USC3731); CMS MLN # SE1022 and 42 CFR § 422.504


Exempt= Exempt from Destruction Request Requirement, FE = Fiscal-year End, GR = General Records Schedule, HR = Health Records Schedule, US= Until Superseded, PS= Records of Public Safety Agencies (Police, Fire, EMS, ME, etc.)
