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					                                                                                 Division Directive Number
                                                                                           1.060

                                                                              Effective Date: December 4, 2009

                                                                                      Bernard Simons
                                                                                  Bernard Simons, Director


Title: Review and Retention of Consumer Records/Filing Management Procedures

Application: All state employees of the Department of Mental Health, Division of Developmental Disabilities

Purpose: To ensure the proper and consistent management, handling, and retention of consumer records in
compliance with federal and state laws and professional practice standards; to ensure accessibility and
confidentiality of records in compliance with HIPAA regulations.

       SECTION I. RECORDS MANAGEMENT: STORAGE, RETENTION & DESTRUCTION

Please refer to HIPAA Department Operating Regulation (DOR) 8.110 for rules pertaining to storage, retention
and destruction of protected health information. “There shall be no facility policies pertaining to this topic. The
Department Operating Regulation shall control.”

Standardized Record Filing Order

A standard order for all consumer records retained in Regional Offices has been established and should be
followed (see Appendix A: Standardized Record Filing Order).

It is highly recommended that all other Targeted Case Management (TCM) providers adopt the same standard
filing order to maintain consistency statewide and to facilitate transfers between Regional Offices and TCM
entities in different locations.

                                    SECTION II. TRANSFER OF RECORDS

The procedure for administrative transfers between Regional Offices is described in Division Directive 5.010 -
Administrative Transfer Policy.

The procedure for administrative transfers between Regional Offices and County Senate Bill 40s/other TCM
entities is described in Appendix B: SB40/Other TCM Entity Records Reference Guide.

                                  SECTION III. RETENTION OF RECORDS

Procedures and specific time guidelines for the retention of consumer records are outlined in DOR 8.110.




1.060 Review and Retention of Consumer Records/Filing Management Procedures                                  Page 1
Authority

Division Directive 5.010 - Administrative Transfer Policy
DOR 8.005 Notice of Privacy Practices Procedures
DOR 8.010 Amendment of Protected Health Information
DOR 8.020 Consumer Right to Request Restrictions on the Use or Disclosure of Protected Health Information
DOR 8.030 Access to Consumer Protected Health Information by Consumer, Parent, Guardian or Personal Representative
DOR 8.040 Access to Consumer Protected Health Information (PHI) by Department of Mental Health Staff, Volunteers or Students
DOR 8.050 Policy and Procedures for Obtaining Authorization for the Disclosure of Protected Health Information
DOR 8.060 The Provision of Accounting of Disclosures of Protected Health Information to Consumers
DOR 8.070 Policy and Procedures for the Verification of Identity and Authority of Requestor
DOR 8.080 Ensuring Confidentiality of Protected Health Information for DMH Staff Working Away from a Facility Setting
DOR 8.090 Mandatory HIPAA Privacy and Security Training
DOR 8.100 Designated Records Set
DOR 8.110 Retention and Protected of Protected Health Information
DOR 8.140 HIPAA Complaint Process
DOR 8.150 HIPAA Minimum Necessary Standard
DOR 8.160 HIPAA Sanctions




1.060 Review and Retention of Consumer Records/Filing Management Procedures                                           Page 2
                                     APPENDIX A
                           STANDARDIZED RECORD FILING ORDER
Records Management

NEW CONSUMER                                              CURRENT CONSUMER
Originals at the Regional Office and Copies to the        Originals at the Regional Office and Copies to the TCM
TCM Entity                                                Entity
Documents:                                                Admission Documents:
       Eligibility Determination and Admission                    Collateral related to eligibility
       information                                                Current diagnosis and supporting collateral
       Assessments and reports used to determine                  Eligibility determination final form to include diagnosis
       eligibility (collateral)                                   Eligibility determination report
       Application information                                    Choice of Provider form – TCM Provider, services, etc
       Client Rights receipt                                      Current Consumer Profile sheet from CIMOR
       Diagnosis sheet and supporting documentation
       Most current screening, if receiving active
       treatment
OTHER AGENCY INFORMATION                                  PCP/IFSP/AMENDMENTS: Originals to the TCM Entity -
                                                          No copies at the Regional Office
                                                                  Amendments/addendums to plan
                                                                  Annual plan, to include budget summary plan
                                                                  Behavior plan, if separate
                                                                  School IEP
                                                                  Nursing Home Care plan
                                                                  Children’s Services Case plan (Children’s Division Custody)
                                                                  ICF-MR form (requirement for Waiver Services)
                                                                  Utilization Review Committee Recommendation sheet
                                                                  Most recent progress reports (Judevine, therapies, etc.)

                                                          REVIEWS: Originals to the TCM Entity - No copies at the
                                                          Regional Office
                                                                  30 Day (monthly) program review completed by vendor
                                                                  for current IP year
                                                                  Service Monitoring Review for current IP year
                                                                  Current IP year of PCP reviews
                                                          EVALUATION AND ASSESSMENT: Originals to the
                                                          TCM Entity - No Copies at the Regional Office
                                                                  Psychological Assessment (only most current)
                                                                  Any evaluation of documentation determining diagnosis
                                                                  Social History Assessment – original and most recent
                                                                  Vineland/MOCABI/SIS – most recent
                                                                  Vocational Assessment
                                                                  Diagnostic Summary (Special Education)
                                                                  PT Evaluations
                                                                  OT Evaluations
                                                                  Speech Evaluations

 1.060 Review and Retention of Consumer Records/Filing Management Procedures                                        Page 3
                                                          HEALTH (most current of each): Originals to the TCM
                                                          Entity - No Copies at the Regional Office
                                                                  Physical Examination, including labwork
                                                                  Dental Examination
                                                                  Audiological report
                                                                  Consultation report and request (physician and
                                                                  habilitation center)
                                                                  Physical reports and notes
                                                                  Hospital discharge plan
                                                                  Physician’s orders and progress/program notes
                                                                  Regional Office RN Health Inventory
                                                                  Report of Hepatitis B Status
                                                                  Immunization Records
                                                                  NHRA (not required yearly) request most current if
                                                                  consumer is on current Regional Office census
                                                          CASENOTES: Originals to the TCM Entity - No Copies at
                                                          the RO
                                                                  Case Manager case notes/TCM log notes for one year
                                                                  (only until CIMOR access is gained)
LEGAL: Copies at the RO                                   LEGAL: Originals to the TCM Entity
       Guardianship Letters                                       Court Orders
       Conservatorship Letters                                    Subpoenas
                                                                  Guardianship Letters
                                                                  Conservatorship Letters
                                                                  Birth Certificate
                                                                  Social Security Card
                                                                  Missouri Medicaid/Medicare Card
                                                                  Client Rights Receipt Form
                                                                  Client Choice of Provider Statement
                                                                  Notice of Right to Choose Form (Olmstead)
                                                                  Adoption Papers
                                                                  Divorce Decree/Child Custody Documents
                                                                  Consumer Marriage Certificate
                                                          FINANCIAL: Originals to the TCM Entity - No Copies at
                                                          the Regional Office
                                                                  Insurance Policies
                                                                  Burial Policies (Continental Life)
                                                                  Medication allowance request (ancillary)
                                                                  ISL Budget and Staffing Pattern
                                                                  Individual Plan of Care (IPC Funding Authorization)
                                                                  Spenddown information
                                                                  Medicaid eligibility
                                                                  Medicare (specifically part D) to include provider
                                                                  Medicaid Reinvestigation Information




 1.060 Review and Retention of Consumer Records/Filing Management Procedures                                      Page 4
STANDARDIZED RECORD FILING ORDER:
  RECOMMEND THE FOLLOWING TABS BE MAINTAINED IN THE TCM PROVIDER FILE, WITH
                                  DOCUMENTS AS LISTED, IN ORDER
ADMISSION/DISCHARGE TAB:
     DMH Change of Status
     Eligibility Determination and Admission information
     Assessments and reports used to determine eligibility (collateral)
     Application Information
     Diagnosis sheet and supporting documentation
LEGAL DOCUMENTS TAB:
     Court Orders
     Subpoenas
     Guardianship letters
     Conservatorship letters
     Birth Certificate
     Missouri Medicaid/Medicare card
     Choice of Provider statements – Waiver and Services
     HIPAA Privacy Acknowledgement
     Authorization to Disclose Client Medical and Health Information
     Client Rights Receipt
     Notice of Right to Choose (Olmstead)
     Adoption Papers
     Divorce Decree/Child Custody Documents
     Consumer Marriage Certificate
CURRENT PERSON-CENTERED PLAN TAB:
     Individual plan, to include budget summary
     Amendments
     Client profile
     Behavior plan
     ICF-MR form
     Utilization Review Recommendation sheet
OTHER AGENCY INFORMATION TAB:
     IEP
     Nursing Care Plan
     Children’s Division Case Plan
     Vocational Plans
     Health and Senior Services
SUMMARIES / REVIEWS TAB:
     Progress notes from agencies (Judevine, therapies, etc.)
     Plan reviews
     Service Monitoring
CORRESPONDENCE TAB:
     All correspondence for plan year
     IP signature letters
     Medicaid Waiver eligibility/appeal letters



1.060 Review and Retention of Consumer Records/Filing Management Procedures   Page 5
FINANCIAL TAB:
       Individual Plan of Care (IPC)
       Insurance Policies
       Burial Policies (Continental Life)
       Medication Allowance Request (Ancillary)
ASSESSMENTS AND EVALUATIONS TAB:
       Evaluation of Need for ICF-MR Level of Care
       Eligibility for Waiver
       Functional Assessment
       SIS
       Vineland/MOCABI
       Psychological/Psychiatrist Evaluations
       Vocational Evaluation
       Therapy Evaluations (OT, PT, Speech)
       Other Evaluations and Assessments
HEALTH TAB:
       Physicals
       Dentals
       RN Health Inventory
       Hepatitis B Status Form
       Immunizations
       Physician’s order/reports
       Hospital Discharge plans
       Other Health Information
“OTHER” TAB:
       Newspaper clippings
       Photos
       Referrals
RECOMMEND TCM PROVIDER RETAIN THE FOLLOWING:
       Current consumer file, with documents for 1 year
       Culminate file on a yearly basis
       Historical file (to be microfilmed) after 7 years
       Transfer to Regional Office for disposition
Various sources require different retention schedules. CARF and CQL require agencies to follow the policies of
the funding source:
       TCM Manual – Medicaid may audit 5 years back
       Waiver Manual – Providers must retain records for six years from the date of service
       HIPAA – Requests for information – 6 years; Records related to services – 6 years from date of service
       Medicare – Providers records 5 years
       SOS for SB40 Boards – 7 years (Refers to Sheltered Workshop Documents)
       DOR8.110 – Permanent Retention for some; others 6 years; records for minor children 3 years after they
       reach legal age
       Division of Medical Services – 5 years from date of service
       Transfer of Records from one TCM Provider to another TCM Provider will be completed electronically
       through PDF documents, as appropriate, with hard files transferred as currently done.



1.060 Review and Retention of Consumer Records/Filing Management Procedures                            Page 6
                                                  APPENDIX B



    SB40/OTHER TCM ENTITY
      RECORDS REFERENCE
            GUIDE

                If you have any questions regarding records, feel free to
                contact your Regional Office Client Information Center.




TABLE OF CONTENTS

     RECORDS HIPAA PRIVACY & SECURITY – pg 8
     AUDITS AND SPECIAL REQUESTS – pg 8
     RECORD KEEPING – Filing Order / Tabs / Retention Schedule & Archiving
     pg 8
     CIMOR – Updating Consumer Demographics In CIMOR Database And
     Changing Service Coordinators – pg 8
     DIAGNOSIS – Updating The Diagnosis (A Step-By-Step Process) - pg 9
     DISCHARGE & DEATH – Guidelines For Discharging From Services – pg 9
     TRANSFERS - From SB40 County To Another Region – pg 9




1.060 Review and Retention of Consumer Records/Filing Management Procedures   Page 7
RECORDS HIPAA PRIVACY & SECURITY
    All new SB40 staff working near the location of PHI must receive HIPAA Privacy Training.
    Training is to be done by the TCM Agency.
    All records must be maintained in a secured area. Examples: A room designated for consumer records with
    a secure door, locked when no staff are present; or records placed in filing cabinets with a secure locking
    system.
    Consumer records cannot be taken outside building.
    Exceptions include:
        a. Receipt of a court order which subpoenas the record
        b. Record is being transported to the Regional Office upon discharge or transfer
    Each consumer record is required to contain an access/checkout form. This form should include a place for
    the staff to write the following:
        a. Name of staff viewing record
        b. Date accessed
        c. Purpose of record access

 SPECIAL NOTE: Authorizations for disclosure of confidential consumer information cannot
 be shared between the Regional Office and a SB40 Board. This does not apply to SB40 Boards
 providing TCM due to contract stipulations.


AUDITS AND SPECIAL REQUESTS
    If Regional Office receives an audit or special request (not requiring authorization), we will contact the
    SB40 staff by email, advising specifics such as information requested and any specified timelines which
    may apply.
RECORD KEEPING – Filing order / Tabs / Retention schedule & Archiving
    See: Record Management for Service Coordination guide.
    When records are purged and ready for archiving, please contact the Regional Office records staff to make
    arrangements for transportation and receipt.
CIMOR – Updating consumer demographics in CIMOR database
    Regional Office staff will provide training and technical assistance as needed.
    SB40 staff may need CIMOR computer training and proper access to fulfill their duties.
    SB40 staff will need to update information such as: name changes, address, telephone, guardianship changes
    and other consumer resources, etc., in CIMOR.
    Note: Official documents such as the birth certificate or court order must be secured, before changing the
    consumer name in CIMOR. After updating CIMOR, perform the following:
       a. Print the EOC Summary & Consumer Face Sheet Summary, and then file in record.
       b. Send an encrypted email update to the Regional Office CIC staff.
    Changing Service Coordinators (SC) in CIMOR:
    When a consumer receives a new Service Coordinator, CIMOR’s Consumer Resources must be updated
    with the new SC staff member under Staff/Int Parties.

    NOTE: Two SC staff CANNOT be effective for the same day in CIMOR (see example below).

      Name        Relationship      Employee       Practitioner    Primary    Emergency     From            To
    Previous   DD Private Service
                                       Yes             Yes            No         No       10/09/2008    11/11/2008
    staff      Coordinator
    New SC     DD Private Service
                                       Yes             Yes            No         No       11/12/2008
    staff      Coordinator


1.060 Review and Retention of Consumer Records/Filing Management Procedures                                Page 8
DIAGNOSIS – Updating the Diagnosis (a step-by-step process)

   It is imperative to maintain a current diagnosis in CIMOR. When documentation is received
   by SB40/other TCM entity staff indicating a change in a consumer diagnosis, the following
   process will be utilized.
  1. SB40/other TCM entity staff will copy all documents pertaining to the updating of
     consumer diagnosis. Examples could include: medical reports, evaluations, IEP, etc.
  2. SB40/other TCM entity staff will forward documents to the Regional Office (RO)
     diagnostician.
  3. RO diagnostician will review information and create a new Diagnosis Sheet.
  4. RO diagnostician will forward to RO CIC staff.
  5. RO CIC staff will update diagnosis in CIMOR for both RO & SB40/other TCM entity.
  6. RO CIC staff will print the updated EOC Summary & Face Sheet. This will be mailed
     along with a copy of the Diagnosis Summary to the SB40/other TCM entity.

DISCHARGE & DEATH – Guidelines for Discharging From Services
    The SB40 Service Coordinator will complete a Discharge or Death Summary and forward to the Regional
    Office CIC, along with the consumer records. In cases of consumer death, the exact date of death must be
    used as the official discharge date.
    Regional Office CIC staff will enter the discharge in CIMOR for the SB40 & RO and update the RO master
    index.
    All original records generated by the Regional Office and the SB40 Board will be sent to Regional Office
    upon discharge by either:
            a. Hand delivered by SB40 staff to Regional Office
            b. Mailed by USPS, certified with return receipt to Regional Office
     An Official Transfer of Consumer Records document is required to be completed and sent with the original
    consumer record for tracking purposes.

TRANSFERS - From SB40 to Another Region or County
    Other related documents:
            a. Record Management for Service Coordination guide
            b. Transfer document
    Transfer summary will be completed by SB40 staff and forwarded by email to the Regional Assistant
    Director.
    All original records will be forwarded to the Regional Office upon official acceptance of transfer by either:
            a. Hand delivered by SB40 staff to Regional Office
            b. Mailed by USPS, certified with return receipt to Regional Office




1.060 Review and Retention of Consumer Records/Filing Management Procedures                              Page 9

				
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