DAL 15-06: Safe Recordkeeping

June 3, 2015

DAL: DAL 15-06

SUBJECT: Safe Recordkeeping

Dear Administrator:

The purpose of this letter is to emphasize and clarify the Department of Health's (DOH) expectations regarding storage and maintenance of facility and resident records. It is the operator's responsibility to ensure that resident and facility records, under their custody, are stored in a secure location which maintains the physical integrity of the records in addition to safeguarding the records from the potential for environmental damage.

Should an unexpected event occur in which resident and/or facility records are damaged, the Operator must immediately notify their DOH Regional Office and take the necessary actions to salvage the damaged records. Actions at a minimum should include, relocating the records to a safe environment, contacting a restoration company and taking appropriate steps to remediate the problem to prevent additional damage. Additionally, if your facility receives Medicaid funding for services provided in your facility, Federal law and State regulations require Medicaid providers to maintain records necessary to fully disclose the extent of services, care and supplies provided to Medicaid recipients for a period of six years. The Office of the Medicaid Inspector General (OMIG) published an article in the Medicaid Update regarding the loss of records due to unforeseen incidents. A copy of that publication is enclosed.

DOH also advised providers during Hurricane Sandy, that only an independent expert should verify that records can or cannot be salvaged. If the records are salvageable, the DOH expects the Operator will take the appropriate action to save the records in accordance with the various record retention requirements. If it is determined that the records are unsalvageable, the Operator has an obligation prior to disposing of or abandoning the damaged records, to determine if the records must be rendered unusable, unreadable or indecipherable.

Operators should maintain both documentation and evidence of the destruction. Paper, film or other hard copy records must be shredded or properly destroyed in such a manner that prevents the information used to identify residents from being read or reconstructed. It should be noted that the destruction of damaged Medicaid records does not alleviate the records retention obligations in support of payments received for claims filed.

In the event of an audit by the Office of the Medicaid Inspector General (OMIG), OMIG will evaluate, on a case-by-case basis, whether there are mitigating circumstances for all missing or damaged documents.

If you have any additional questions regarding safe recordkeeping, please contact your appropriate Regional Office. As always, thank you for your continued cooperation.


Valerie A. Deetz, Director

Division of Adult Care Facility and Assisted Living Surveillance