Retention and Destruction/Disposal of Private and Confidential Information: Difference between revisions

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Policy No.: '''6056'''<br />
Policy No.: '''6056'''<br />
Effective Date: '''03/17/03'''<br />
Effective Date: '''03/17/03'''<br />
Revised Date: '''05/22/17''' <br />
Revised Date: '''08/29/22 draft''' <br />
Reviewed Date: '''05/22/17'''
Reviewed Date: ''' '''
<br /><br />
<br /><br />
<big>'''Retention and Destruction/Disposal of Private and Confidential Information Policy'''</big>
<big>'''Retention and Destruction/Disposal of Private and Confidential Information Policy'''</big>
== Basis for Policy ==
== Basis for Policy ==
Retention and subsequent destruction/disposal of proprietary and protected health information are governed by federal and state regulations and University policies and procedures. These regulations and guidelines include, but may not be limited to:
Nebraska Medicine/UNMC implements reasonable and appropriate access controls in alignment with National Institute of Standards and Technology (NIST) standards and guidance to maintain the minimum necessary access. NIST Special Publication 800-53 and the HIPAA Security Rule outline considerations for the access control family of security controls.
*Health Insurance Portability and Accountability Act of 1996 (HIPAA)
*Executive Memorandum No. 27, HIPAA Compliance Policy
*Board of Regents Bylaws
*Board of Regents Policies
*Privacy, Confidentiality and Information Security Policy
*Institutional Review Board Guidelines, Retention of Research Records for Non-Exempt Research
*Information Technology Services Procedures
*[http://www.sos.ne.gov/records-management/schedule_170.html UNMC Record Retention Schedule]
==Policy==
==Policy==
===Retention===
1#It is the policy of the UNMC/Nebraska Medicine and its affiliated entities to ensure the privacy and security of confidential information in the maintenance, retention and eventual destruction/disposal of such media. All destruction/disposal of confidential information media will be done in accordance with federal and state law and pursuant to the [http://www.sos.ne.gov/records-management/schedule_170.html UNMC Record Retention Schedule]. Records that have satisfied the period of retention will be destroyed/disposed of in an appropriate manner.  
It is the policy of the University of Nebraska Medical Center (UNMC) and its affiliated entities to ensure the privacy and security of confidential information in the maintenance, retention, and eventual destruction/disposal of such media. All destruction/disposal of confidential information media will be done in accordance with federal and state law and pursuant to the UNMC Record Retention Schedule. Records that have satisfied the period of retention will be destroyed/disposed of in an appropriate manner.  
#Records involved in any open investigation, audit or litigation should not be disposed of/destroyed. If a preservation notice is received the record retention schedule shall be suspended for these records until the preservation notice terminates.
 
#Records scheduled for destruction/disposal should be secured against unauthorized or inappropriate access until the destruction/disposal of the information is complete.
The retention schedule for destruction/disposal shall be suspended for records involved in any open investigation, audit, or litigation, as well as where specific contract provisions specify record retentions requirements.  
#Private and confidential information shall be destroyed/disposed of using a method that ensures the information cannot be reconstructed or read.
 
#Individuals who know or suspect that confidentiality has been breached by another person or persons have a responsibility to report the breach to the respective supervisor or to the Human Resources Department. Employees should not confront the individual under suspicion or initiate investigations on their own, as such actions could compromise any ensuing investigation. All individuals are to cooperate fully with those performing an investigation pursuant to this policy.
Individuals who know or suspect that confidentiality has been breached by another person or persons have a responsibility to report the breach to the respective supervisor or administrator or to the Human Resources Department. Employees should not confront the individual under suspicion or initiate investigations on their own, as such actions could compromise any ensuing investigation. All individuals are to cooperate fully with those performing an investigation pursuant to this policy.  
==Procedures==
 
#If destruction/disposal services are contracted, the contract must provide that the contactor (Business Associate) will establish the permitted and required uses and disclosures of information as set forth in the federal and state law (in accordance with UNMC Policy No. 8009, [[Contracts]], ''' “Contract Management Policy”). Does Nebraska Medicine also have a policy to reference? If so, need policy #''') and include the following elements:
If a preservation notice is received, the record retention schedule shall be suspended until the preservation notice terminates.
##Specify the method of destruction/disposal
===Disposal/Destruction===
##Specify the time that will elapse between acquisition and destruction of data/media
All paper waste must be placed in a recycling container. UNMC will ensure that all confidential paper waste is secured from the time it is collected until the time it is shredded by the selected vendor.
##Establish safeguards against breaches in confidentiality
 
##Indemnify the organization from loss due to unauthorized disclosure
Records scheduled for destruction/disposal should be secured against unauthorized or inappropriate access until the destruction/disposal of information is complete.
##Require that the contractor (Business Associate) maintain liability insurance in specified amounts at all times the contract is in effect
 
##Provide proof of destruction/disposal
Failure to appropriately dispose of/destroy private or confidential information may result in sanctions, civil or criminal prosecution and penalties, scholastic or employment corrective action which could lead to dismissal or, as it relates to health care professionals or others outside of UNMC, suspension or revocation of all access privileges.
#Confidential information shall be disposed of according to the table below:
===Definitions===
{| class="wikitable"
'''Information''' is data presented in readily comprehensible form. (Whether a specific message is informative or not depends in part on the subjective perceptions of the person who receives it.)  Information may be stored or transmitted via electronic media, on paper or other tangible media, or be known by individuals or groups.  Information generated in the course of University operations is a valuable asset of the University and belongs to the University.  
|-
 
|'''Medium'''||'''Destruction Procedure(s)'''
'''Proprietary information''' refers to information regarding business practices, including but not limited to, financial statements, contracts, business plans, research data, employee records and student records: 
|-
*'''Employee records''' refers to all information, records and documents pertaining to any person who is an applicant or nominee for any University personnel position described in the Board of Regents Bylaws, §3.1, regardless of whether any such person is ever actually employed by the University, and all information, records and documents pertaining to any person employed by the University.
| Paper|| All paper should be disposed of in the desk-side recycling bins, the recycling carts or shredded in a shredding machine. All paper is considered confidential in the recycling process. Food waste and toiletry products are excluded and should not be placed in the recycling bins.
*'''Student education records''' means any information recorded in any way which directly relates to a student and is maintained by or on behalf of UNMC (education agency/institution). <br />
|-
Student education record does not include a (i) sole possession record, (ii) law enforcement record, (iii) employee record of a person other than a student who is employed by UNMC by virtue of his or her status as a student at UNMC, (iv) alumni record and (v) medical record that is part of the common medical record shared by UNMC, The Nebraska Medical Center, UMA and UDA. (NOTE: The HIPAA privacy regulation does not apply to education records covered by FERPA.)
| Audiotapes/Videotapes || Tape over the information or forward the audio/videotape to Environmental Services (DOC 0647; zip 9030) in a sealed package for destruction. Place a "Please Destroy" label on the tape.
|-
| CD ROMs/DVDs || Cut in two and dispose of in trash.
-Large volumes of CDs may be forwarded to Environment Services.
|-
| Cell Phones || Cell phones which are no longer in use shall be returned to Information Technology who will dispose of the equipment.
|-
| Computerized Data/Hard Disk Drives
'''(NOTE:''' This includes hard drives in any devices, including copy machines or devices with non-removable hard drives)
|| This section includes tablet devices (such as iPads, Samsung Tablets, etc.) as well as laptops with non-removable hard drives (such as MacBooks or Surface computers).


'''Protected Health Information''' (PHI) is individually identifiable health information.  Health information means any information, whether oral or recorded in any medium, that: 
Requestor will enter a Service Request containing the following information:<br />
*is created or received by UNMC; and
1. Request to decommission a data/hard disk storage device<br />
*relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.
2. A statement that records are being destroyed in the normal course of business pursuant to Nebraska Medicine Record Retention Policy<br />
Records containing PHI, in any form, may not be deleted. PHI contained in the medical record must be accessible at all times.
3. Name of the department representative authorizing data destruction<br />
4. Phone number of representative authorizing destruction<br />
5. Requestor will then arrange secure delivery of devices to North Doctors Building, Ground Floor, to PC Support. <br />
6. PC Support will receive and will securely store the devices until physically destroyed.<br />
7. Final destruction and salvage take place in IT. <br />
8. Questions regarding this process can be directed to PC Support Dispatch at 402-552-7777.<br />
'''NOTE:''' In the circumstances where a copier is being traded out, PC Support will ensure that the hard drive is secured by following their internal procedures.<br /> 
'''NOTE 2:'''  PC Support may, at its discretion, use data wiping tools to enable reuse of certain hard drives.  PC Support will follow NIST Special Publication 800-88 Guidelines for Media Sanitization which authorizes using the DOD certified standard 5022.22, 3X for wiping
|-
| Cassette Tapes/Magnetic Media|| Forward to Environmental Services (DOC 0647; zip 9030) in a sealed container for destruction. Place a "Please Destroy" label on the media.
|-
| Computer Diskettes/Floppy Disks || Forward to Environmental Services (DOC 0647; zip 9030) in a sealed container for destruction. Place a "Please Destroy" label on the media.
|-
| Laser Disks|| Forward to Environmental Services (DOC 0647; zip 9030) in a sealed container for destruction. Place a "Please Destroy" label on the media.
|-
| Microfilm/Microfiche || Forward to Environmental Services (DOC 0647; zip 9030) in a sealed container for destruction. Place a "Please Destroy" label on the media.
|-
| Photographs || Photographs should be shredded or cut in multiple pieces. Photographs should not be placed in recycling containers.
|-
| Radiology Films || Refer to Radiology Dept. Policy, LR - 6.12, "Retention/Disposal of Radiology Images" '''is this a Nebraska Medicine or UNMC policy?'''
|-
| Printer Ribbons || Forward to Environmental Services (DOC 0647; zip 9030) in a sealed container for destruction. Place a "Please Destroy" label on the media.
|-
| Other || Follow federal/state requirements; contact the Director, Environmental Services, at 402-559-6118, '''(do you have a better number for them?)''' or [mailto:debrbishop@nebraskamed.com Privacy Officer] for further information.
|}
===Destruction of Paper===
#Handling and Security Procedures
##Departmental management and Environmental Services should jointly develop a plan for the security, transport and storage of confidential materials from customer departments to the secured locked containers. The placement of the secured locked containers will be jointly developed between departmental management, [mailto:rboldt@unmc.edu Recycling Coordinator] and Environmental Services.
##Locked containers should not be tampered with by unauthorized UNMC/Nebraska Medicine employees.
##Environmental Services will be responsible for issuing and logging the keys for unlocking these containers.
#Documentation of Secure Disposal


The Certificate of Destruction for all recycled UNMC/Nebraska Medicine confidential material will be kept on file in the Recycling Coordinator’s office.
==Definitions==
===Affiliated Covered Entity (ACE)===
Legally separate covered entities that designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current ACE members are: The Nebraska Medical Center, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members. Access and amendment rights apply to designated record sets throughout the ACE.
===Business Associate===
A third party that performs services on behalf of Nebraska Medicine/UNMC (that involve the creation, receipt, maintenance or transmission of protected health information). Some examples of such services include claims processing, data analysis, data processing, practice management, utilization review, quality assurance, patient safety activities, billing, benefit management and repricing.
===Confidential Information===
Individually-identifiable health information (protected health information) and proprietary information, including contracts, business plans and practices, financial information, employee records and meeting minutes.
==Additional Information==
==Additional Information==
*Contact the [mailto:infosecurity@unmc.edu Information Security Office]
*Contact the [mailto:infosecurity@unmc.edu Information Security Office]
*Contact Director, Environmental Services, at 402-559-6118, '''(do you have a better number for them?)'''
*[mailto:rboldt@unmc.edu Recycling Coordinator]
*Contact [mailto:debrbishop@nebraskamed.com Privacy Officer]
*Procedure No. 6056, [https://info.unmc.edu/its-security/policies/procedures/destruction-confinfo.html Destruction of Private and Confidential Information]
*Procedure No. 6056, [https://info.unmc.edu/its-security/policies/procedures/destruction-confinfo.html Destruction of Private and Confidential Information]
*UNMC Policy No. 8009, [[Contracts]]
*[http://www.sos.ne.gov/records-management/schedule_170.html UNMC Record Retention Schedule]
*[http://www.sos.ne.gov/records-management/schedule_170.html UNMC Record Retention Schedule]
*Radiology Dept. Policy, LR - 6.12, Retention/Disposal of Radiology Images
*“Contract Management Policy”)


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