I know one of the things some of you are doing with extra staff time is cleaning up your consumer records. You may call these Consumer Service Records or Consumer information Files or choose some other designation, but the bottom line is that you have a record of the services you provide to an eligible individual. Here are a few items for you to keep in mind.
- All records of individuals served are confidential. Whether you keep private identifying information (social security numbers?) or medical information (neither required by IL but sometimes needed for other services), your records and information about those you serve is confidential. You must keep them locked and password protected. Extra tip: Sometimes consumer information isn’t in the paper or computer file. Sometimes it is in an activity list, a birthday calendar or a mailing or email list. Keep these confidential, too.
- Your records must document what your annual reports (PPRs) indicate. How do you demonstrate who you serve, their disability (eligibility) and their desire to have an Independent Living Plan (or waive it)? Right now, all across the country, Centers are pulling reports from their consumer data base to use in completing their Program Performance Report. Look at them closely. Do they make sense? Do the staff seem knowledgeable in how to document? Run a cross-check by staff member to pick up any reporting inconsistencies. Make sure that the information in your PPR is an accurate reflection of the services provided. Extra tip: If you find anything that you have to go back and calculate by hand for the PPR you are working on now, train staff in corrections now so the reports for the current year are accurate.
- Review the COMP documents for more details. If your center is reviewed by your federal funder, it will be reviewed using the COMP materials provided by the Office of Independent Living Programs. You can find those materials here. Extra tip: One of the documents in the COMP process is a Consumer Information File Checklist that will help you double check all your records.
- Follow your own policies. You should have policies and procedures that specify when a file is closed and why, and a policy on how long you retain consumer records. You must demonstrate that you follow your own policies including these. If you destroy inactive records after seven years, for example, you shouldn’t hang on to inactive records that are 30 years old. Extra tip: Set a specific time for data entry. Some centers set a half day a week when they don’t see consumers so that staff are always caught up on data entry. You also want to set time for file review. This is done annually in small organizations, but may be done monthly or quarterly if needed. It is good practice to have staff review each other’s files from time to time, if your confidentiality policy allows that, so that staff can learn from each other’s processes.
A note about HIPPAA: Centers for Independent Living are not medical entities and are not typically bound by HIPPAA. However, you may have a specific funding source that requires this level of confidentiality. Follow the requirements related to that funding. You can institute that level of confidentiality for all of your consumer records if you wish.