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

From University of Nebraska Medical Center
Jump to navigation Jump to search
No edit summary
No edit summary
Line 37: Line 37:
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.  [https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final NIST Special Publication 800-53] and the [https://www.cdc.gov/phlp/publications/topic/hipaa.html#security-rule HIPAA Security Rule] outline considerations for the access control family of security controls.   
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.  [https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final NIST Special Publication 800-53] and the [https://www.cdc.gov/phlp/publications/topic/hipaa.html#security-rule HIPAA Security Rule] outline considerations for the access control family of security controls.   
==Policy==
==Policy==
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 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.  
#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 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.
#Records scheduled for destruction/disposal should be secured against unauthorized or inappropriate access until the destruction/disposal of the information is complete.
Line 55: Line 55:
|'''Medium'''||'''Destruction Procedure(s)'''
|'''Medium'''||'''Destruction Procedure(s)'''
|-
|-
| 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.
| 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 recycling bins.
|-
|-
| 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.
| Audiotapes/Videotapes  || Tape over the information or forward the audiotape/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.
| CD ROMs/DVDs || Cut in two and dispose of in trash.
-Large volumes of CDs may be forwarded to Environment Services.
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.
| Cell Phones || Cell phones which are no longer in use shall be returned to Information Technology who will dispose of the equipment.
Line 70: Line 71:
Requestor will enter a Service Request containing the following information:<br />
Requestor will enter a Service Request containing the following information:<br />
1. Request to decommission a data/hard disk storage device<br />
1. Request to decommission a data/hard disk storage device<br />
2. A statement that records are being destroyed in the normal course of business pursuant to Nebraska Medicine Record Retention Policy<br />
2. A statement that records are being destroyed in the normal course of business pursuant to Nebraska Medicine Record Retention Policy ('''is there a policy number?''')/[http://www.sos.ne.gov/records-management/schedule_170.html UNMC Record Retention Schedule] <br />
3. Name of the department representative authorizing data destruction<br />
3. Name of the department representative authorizing data destruction<br />
4. Phone number of representative authorizing destruction<br />
4. Phone number of representative authorizing destruction<br />
Line 78: Line 79:
8. Questions regarding this process can be directed to PC Support Dispatch at 402-552-7777.<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:'''  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
'''NOTE 2:'''  PC Support may, at its discretion, use data wiping tools to enable reuse of certain hard drives.  PC Support will follow [https://csrc.nist.gov/publications/detail/sp/800-88/rev-1/final NIST Special Publication 800-88 Rev. 1, 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.
| 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.
Line 84: Line 85:
| 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.
| 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.
| Laser Disks|| Forward to Environmental Services (DOC 0647; zip 9030) in a sealed container for destruction. Place a "Please Destroy" label on the disks.
|-
|-
| Microfilm/Microfiche || 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 microfilm/microfiche.
|-
|-
| Photographs || Photographs should be shredded or cut in multiple pieces. Photographs should not be placed in recycling containers.
| Photographs || Photographs should be shredded or cut in multiple pieces. Photographs should not be placed in recycling containers.
Line 92: Line 93:
| Radiology Films || Refer to Radiology Dept. Policy, LR - 6.12, "Retention/Disposal of Radiology Images" '''is this a Nebraska Medicine or UNMC policy?'''
| 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.
| Printer Ribbons || Forward to Environmental Services (DOC 0647; zip 9030) in a sealed container for destruction. Place a "Please Destroy" label on the container.
|-
|-
| 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.
| 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.
Line 102: Line 103:
##Environmental Services will be responsible for issuing and logging the keys for unlocking these containers.
##Environmental Services will be responsible for issuing and logging the keys for unlocking these containers.
#Documentation of Secure Disposal
#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.
The Certificate of Destruction for all recycled UNMC/Nebraska Medicine confidential material will be kept on file in the Recycling Coordinator’s office.
==Definitions==
==Definitions==
Line 114: Line 114:
*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?)'''  
*Contact Director, Environmental Services, at 402-559-6118, '''(do you have a better number for them?)'''  
**Contact Human Resources – Records at 402-559-8962 or Human Resources - Employee Relations  
*Contact Human Resources – Records at 402-559-8962 or Human Resources - Employee Relations  
*Contact [mailto:rboldt@unmc.edu Recycling Coordinator]
*Contact [mailto:rboldt@unmc.edu Recycling Coordinator]
*Contact [mailto:debrbishop@nebraskamed.com Privacy Officer]  
*Contact [mailto:debrbishop@nebraskamed.com Privacy Officer]  
*Contact PC Support Dispatch at 402-552-7777 ('''is there an email address for this dept?''')
*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]]
*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]
*Nebraska Medicine Record Retention Policy ('''is there a policy number?''')
*Radiology Dept. Policy, LR - 6.12, Retention/Disposal of Radiology Images
*Radiology Dept. Policy, LR - 6.12, Retention/Disposal of Radiology Images
*“Contract Management Policy”)
*Contract Management Policy '''(policy number needed)'''
*[https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final NIST Special Publication 800-53]
*[https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final NIST Special Publication 800-53]
*[https://www.cdc.gov/phlp/publications/topic/hipaa.html#security-rule HIPAA Security Rule]  
*[https://www.cdc.gov/phlp/publications/topic/hipaa.html#security-rule HIPAA Security Rule]  
*[https://csrc.nist.gov/publications/detail/sp/800-88/rev-1/final NIST Special Publication 800-88 Rev. 1, Guidelines for Media Sanitization]


This page maintained by [mailto:dpanowic@unmc.edu dkp].
This page maintained by [mailto:dpanowic@unmc.edu dkp].

Revision as of 11:16, August 30, 2022

Human Resources   Safety/Security   Research Compliance   Compliance   Privacy/Information Security   Business Operations   Intellectual Property   Faculty


Identification Card | Secure Area Card Access | Privacy/Confidentiality | Computer Use/Electronic Information | Retention and Destruction/Disposal of Private and Confidential Information | Use and Disclosure of Protected Health Information | Notice of Privacy Practices | Access to Designated Record Set | Accounting of PHI Disclosures | Patient/Consumer Complaints | Vendors | Fax Transmissions | Psychotherapy Notes | Facility Security | Conditions of Treatment Form | Informed Consent for UNMC Media | Transporting Protected Health Information | Honest Broker | Social Security Number | Third Party Registry | Information Security Awareness and Training | Patient Privacy Investigations and Levels of Violation | Use and Disclosure of PHI for Training Health Care Professionals | Disclosures of PHI as Permitted or Required by Law | Disclosure of PHI for Law Enforcement Purposes

Policy No.: 6056
Effective Date: 03/17/03
Revised Date: 08/29/22 draft
Reviewed Date:

Retention and Destruction/Disposal of Private and Confidential Information Policy

Basis for Policy

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.

Policy

  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 UNMC Record Retention Schedule. Records that have satisfied the period of retention will be destroyed/disposed of in an appropriate manner.
  2. 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.
  3. Records scheduled for destruction/disposal should be secured against unauthorized or inappropriate access until the destruction/disposal of the information is complete.
  4. Private and confidential information shall be destroyed/disposed of using a method that ensures the information cannot be reconstructed or read.
  5. 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.

Procedures

  1. 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:
    1. Specify the method of destruction/disposal
    2. Specify the time that will elapse between acquisition and destruction of data/media
    3. Establish safeguards against breaches in confidentiality
    4. Indemnify the organization from loss due to unauthorized disclosure
    5. Require that the contractor (Business Associate) maintain liability insurance in specified amounts at all times the contract is in effect
    6. Provide proof of destruction/disposal
  2. Confidential information shall be disposed of according to the table below:
Medium Destruction Procedure(s)
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 recycling bins.

Audiotapes/Videotapes Tape over the information or forward the audiotape/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).

Requestor will enter a Service Request containing the following information:
1. Request to decommission a data/hard disk storage device
2. A statement that records are being destroyed in the normal course of business pursuant to Nebraska Medicine Record Retention Policy (is there a policy number?)/UNMC Record Retention Schedule
3. Name of the department representative authorizing data destruction
4. Phone number of representative authorizing destruction
5. Requestor will then arrange secure delivery of devices to North Doctors Building, Ground Floor, to PC Support.
6. PC Support will receive and will securely store the devices until physically destroyed.
7. Final destruction and salvage take place in IT.
8. Questions regarding this process can be directed to PC Support Dispatch at 402-552-7777.
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.
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 Rev. 1, 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 disks.
Microfilm/Microfiche Forward to Environmental Services (DOC 0647; zip 9030) in a sealed container for destruction. Place a "Please Destroy" label on the microfilm/microfiche.
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 container.
Other Follow federal/state requirements; contact the Director, Environmental Services, at 402-559-6118, (do you have a better number for them?) or Privacy Officer for further information.

Destruction of Paper

  1. Handling and Security Procedures
    1. 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, Recycling Coordinator and Environmental Services.
    2. Locked containers should not be tampered with by unauthorized UNMC/Nebraska Medicine employees.
    3. Environmental Services will be responsible for issuing and logging the keys for unlocking these containers.
  2. 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

This page maintained by dkp.