Start Pg. Box A Document Retention On-Site Storage Worksheet Response Actions Taken Questions, Answers and Actions Documents stored On-site? If yes, go to question ; If no go to the for Off- Site storage. Documents stored in a Secure Location?. Storage location is within the main facility?. Secured behind locked door and access is limited to appropriate facility personnel?. If yes to both. and., skip to Question, If no to either or both. and/or., go to question. Can the documents be secured?. If yes to question, secure documents within the main facility behind a locked door in which access is limited to appropriate personnel at the facility, then go to question.. If no to question, Contact CCD and initiate the "Move Process" by first applying destruction criteria in question 6, continue through question 7 to relocate all stored documents. Pg, Pg, Box C Pg, Box F Pg, Box F 5 6 Are the documents "known"?. Does the facility maintain an accurate log, manifest or inventory of stored material? Documents that are required for recall can be obtained in a timely manner without searching through multiple boxes?. If yes, the documents are Known, go to Question 5; If no skip to question 6. On-site storage location meets requirements? 5. Documents stored on-site require immediate and frequent access or planned storage less than one year? 5. Is an accurate index of all documents maintained? 5. Are all boxes labeled with destruction dates? 5. Are documents destroyed in a timely manner and pursuant to the CHSPSC Document Retention Policy and schedule? 5.5 Is the On-site storage location an effective use of Facility space? 5.6 If the answers to questions 5. - 5.5 are all yes, maintain current On-Site storage area and follow Retention Requirements via CHSPSC Document Retention Policy; If any answer was no, go to question 6. 6. Destroy documents with surpassed retention periods; follow CHSPSC Document Retention 6. Destroy Unknown documents in storage for 5 years or greater; follow CHSPSC Document Retention 6. Excludes documents with a litigation hold - contact Legal if you are unsure if there is an 6. Contact an approved destruction vendor (See Box D on page of the Document Retention Project Tool); Obtain certificate of destruction 6.5 Note number of boxes destroyed, retain Certificate of Destruction and identify any remaining boxes that must be moved to a secure storage location and/or vendor. 6.6 Criteria for every group of Unknown documents in storage less than 5 years: 6.6. A. HIIM Medical Records; contact Regional HIIM Director for guidance 6.6. B. Answer the questions below for each group of Unknown non-medical record documents. 6.6.. Are there any accurate logs, manifests or inventories, formal or informal, maintained for 6.6.. Is a log kept of boxes retrieved from this location? 6.6.. When was the last time a box was retrieved from this location? For what purpose was that 6.6.. What types of documents are stored at this location? 6.6..5 How long have documents been stored at this location? 6.6..6 Were documents stored at this location prior to the acquisition of this facility by CHS? 6.6..7 Are documents currently being added to storage at this location? 6.6..8 When was the last time a box was added to storage at this location? 6.7 Provide answers to the best of your ability, DO NOT index or inventory records, contact CCD for guidance if the records are Unknown and storage time can be confirmed at less than 5 7 Will Documents be moved? On-Site Storage Worksheet: Page of
Pg, Box D Document Retention On-Site Storage Worksheet Response Actions Taken Questions, Answers and Actions Note: prior to initiating the move process, destruction criteria (Box F) must be applied. For any documents not meeting the criteria to be destroyed, execute one or more of the actions below: Medical records in the HIIM Department: contact Regional HIIM Director for guidance storing 7. with EvriChart All other documents, including documents with PHI, but not HIIM department medical records, contact X records storage vendor for previously negotiated discounted pricing 7. 7. If you do not have a contract for document storage, contact your CCD for guidance On-Site Storage Worksheet: Page of
Off-Site Storage Pg, Pg, Pg, Box F Pg, Box F Document Retention Off-Site Storage Worksheet Response Actions Taken Questions, Answers and Actions Are documents stored at Iron Mountain or EvriChart? If yes, go to question ; If no go to the for Other Off-Site storage. Note: Documents stored with Iron Mountain or EvriChart are defined as "Secure". Are the documents "known"?. Does the facility maintain an accurate log, manifest or inventory of stored material? Documents that are required for recall, can be obtained in a timely manner without searching through multiple boxes?. If yes, the documents are Known, go to Question ; If no skip to question.. Have any documents have met required retention period? If yes, go to Question ; If no, Maintain Retention Requirements via CHSPSC Document Retention Policy.. Destroy documents with surpassed retention periods; follow CHSPSC Document Retention. Destroy Unknown documents in storage for 5 years or greater; follow CHSPSC Document Retention. Excludes documents with a litigation hold - contact Legal if you are unsure if there is an. Contact an approved destruction vendor (See Box D on page of the Document Retention Project Tool): Obtain certificate of destruction.5 Note number of boxes destroyed, retain Certificate of Destruction..6 Criteria for every group of Unknown documents in storage less than 5 years:.6. A. HIIM Medical Records; contact Regional HIIM Director for guidance.6. B. Answer the questions below for each group of Unknown non-medical record documents..6.. Are there any accurate logs, manifests or inventories, formal or informal, maintained for.6.. Is a log kept of boxes retrieved from this location?.6.. When was the last time a box was retrieved from this location? For what purpose was that.6.. What types of documents are stored at this location?.6..5 How long have documents been stored at this location?.6..6 Were documents stored at this location prior to the acquisition of this facility by CHS?.6..7 Are documents currently being added to storage at this location?.6..8 When was the last time a box was added to storage at this location?.7 Provide answers to the best of your ability, DO NOT index or inventory records, contact CCD for guidance if the records are Unknown and storage time can be confirmed at less than 5 Off-Site Storage Worksheet: Page of
Other Off-Site Storage Pg. Box B Document Retention Other Off-Site Storage Worksheet Response Actions Taken Questions, Answers and Actions Does the storage vendor meet all Off-site physical security requirements?. Storage vendors has perimeter security (e.g. fence, proximity sensors, monitored cameras, /7 Guard)?. Are all entry points are locked?. Is there controlled access to facility via badge, guard, key or keypad?. All employees must have background checks to screen out potential employees for arrests and/or convictions including: theft and/or identity theft.5 Is an access log maintained for all visitors?.6 Does the storage locations have /7 guard and/or video surveillance?.7 Is there intrusion, fire protection and moisture alarm systems?.8 The storage facility has HVAC climate controlled units to prevent freeze and exposure to extreme heat?.9 Multi tenant storage segregation; Is the CHS affiliate storage inaccessible to others? If yes to questions. -.9 the documents are "Secure", go to question ; If no to any of the questions. -.9, initiate the "Move Process" by first applying destruction criteria in question 7, continue through question 8 to relocate all stored documents. Click here for hyper link to FDQ Pg, Box E Is the storage vendor a Potential Referral Source?. Obtain and review the Financial Disclosure Questionnaire (FDQ). If no, go to question ; If yes initiate the "Move Process" by first applying destruction criteria in question 7, continue through question 8 to relocate all stored documents. Is the financial arrangement cost effective?. Obtain contract or agreement of current vendor that specifies the Other Off-Site storage vendors costs. Open the "Other Off-Site Storage vendor Cost Comparison_Template.xlsx" spreadsheet. Enter the Other Off-Site storage vendor costs for each the billing category that match and review the results in row 0, columns K-M. Review with CFO and determine which vendor is more cost effective for Off-Site storage.. If experiencing issues using the spreadsheet email. If the financial arrangement is cost effective go to step, if not cost effective, initiate the "Move Process" by first applying destruction criteria in question 7, continue through question 8 to relocate all stored documents. Is there a current fully executed contract?. If yes, go to Question 5; If no, contact your CCD ASAP, if required, the respective CCD will engage Legal to determine the next steps. 5 Is there a current *CHS BAA attached to the contract? 5. If yes, maintain Retention Requirements via CHSPSC Document Retention Policy; If no, contact your CCD ASAP, if required, The respective CCD will engage with Legal to determine the next steps. The most current BAA must be executed and in effect. 6 *Use Current CHS BAA Legal and Compliance Team Review 6. Left intentionally blank to document Compliance and Legal team notes and findings. Pg, Box F 7 7. Destroy documents with surpassed retention periods; follow CHSPSC Document Retention 7. Destroy Unknown documents in storage for 5 years or greater; follow CHSPSC Document Retention 7. Excludes documents with a litigation hold - contact Legal if you are unsure if there is an 7. Contact an approved destruction vendor (See Box D on page of the Document Retention Project Tool); Obtain certificate of destruction 7.5 Note number of boxes destroyed, retain Certificate of Destruction and identify any remaining boxes that must be moved to a secure storage location and/or vendor. 7.6 Criteria for every group of Unknown documents in storage less than 5 years: OtherOff-Site Storage Worksheet: Page of
Pg, Box F Document Retention Other Off-Site Storage Worksheet Response Actions Taken Questions, Answers and Actions 7.6. A. HIIM Medical Records; contact Regional HIIM Director for guidance 7.6. B. Answer the questions below for each group of Unknown non-medical record documents. 7.6.. Are there any accurate logs, manifests or inventories, formal or informal, maintained for 7.6.. Is a log kept of boxes retrieved from this location? 7.6.. When was the last time a box was retrieved from this location? For what purpose was that 7.6.. What types of documents are stored at this location? 7.6..5 How long have documents been stored at this location? 7.6..6 Were documents stored at this location prior to the acquisition of this facility by CHS? 7.6..7 Are documents currently being added to storage at this location? 7.6..8 When was the last time a box was added to storage at this location? 7.7 Provide answers to the best of your ability, DO NOT index or inventory records, contact CCD for guidance if the records are Unknown and storage time can be confirmed at less than 5 Pg, Box D 8 Will Documents be moved? Note: prior to initiating the move process, destruction criteria (Box F) must be applied. For any documents not meeting the criteria to be destroyed, execute one or more of the actions below: 8. Medical records in the HIIM Department: contact Regional HIIM Director for guidance All other documents, including documents with PHI, but not HIIM department medical records, contact X records storage vendor for previously negotiated discounted pricing 8. If you do not have a contract with X for document storage, contact your CCD for guidance 8. CHSPSC Compliance Department requires the FCO and CEO to complete a & Attestation to certify complete and accurate review of each Document Retention Project Tool. A signature blank has been provided at the end of the document; typed names will be accepted as signature. By signing this document, you are certifying the following: I certify the Document Retention Project Tool has been completed for each survey response. All issues of concern or non-compliance have been reported to a CHSPSC Compliance Director. FCO Signature Date CEO Signature Date OtherOff-Site Storage Worksheet: Page of