Going Home Staying Home Guidelines for exiting service providers Disposal and storage of client records for which there is no consent to transfer 18 July 2014
Table of Contents 1 PURPOSE... 3 2 CONTEXT... 3 3 KEY DATES... 3 4 DESCRIPTION OF CLIENT RECORDS AND TERMINOLOGY... 4 5 LEGAL AND CONTRACTUAL OBLIGATIONS... 5 6 CONSENT TO TRANSFER RECORDS... 6 7 DISPOSAL OF CLIENT RECORDS FOR WHICH THERE IS NO CONSENT TO TRANSFER... 6 8 STEPS FOR PROCESSING... 6 STEP 1 SENTENCING AND CATEGORISING... 7 STEP 2 CONFIDENTIAL DESTRUCTION OF RECORDS... 8 STEP 3 BOXING... 8 STEP 4 CATALOGUING OF RECORDS... 9 STEP 6 TRANSFER TO FACS BUSINESS SERVICES... 9 Attachments 1. Template for cataloguing records 2
1 Purpose The purpose of the Guidelines for disposal or storage of client records for which there is no consent to transfer (the Guidelines) is to support Specialist Homelessness Service (SHS) providers; Department of Family and Community Services (FACS) funded National Partnership Agreement on Homelessness (NPAH) providers; large community housing providers; and FACS staff in the disposal 1 (destruction or archiving) of client records under Going Home Staying Home (GHSH) where organisations are closing down, do not have client consent to transfer and FACS has agreed to store the records on behalf of the service provider. The Guidelines provide information and guidance on the auditing, sorting (culling for storage, confidential destruction), boxing and transfer of records to storage. The Guidelines should be read in conjunction with the Transition Guidelines. 2 Context The GHSH tender results were announced in June. This has resulted in: Some organisations being successful in their tender it is expected they will retain their client records. Some organisations being unsuccessful in their tender and ineligible or unsuccessful for Service Support Fund (SSF) these organisations, if they decide to close, need to consider their record storage requirements in accordance with the Guidelines. Some organisations being unsuccessful in their tender but successful in receiving funding under the SSF these organisations may need to consider record storage in future, after the period of the SSF. Exiting providers must seek consent from all active clients to transfer their records and make reasonable attempts to obtain consent from inactive clients to transfer their records. Where consent to transfer cannot be obtained, the service provider should consult with FACS to determine the best approach to take with regard to these client records. It is acknowledged that this is a very difficult time for providers, their staff and their clients and that due diligence and duty of care are paramount for all concerned. 3 Key Dates June-July July-September September-October Advise FACS of arrangements for record storage and discuss with FACS whether assistance is needed Audit, cull, catalogue and box records Contact FACS to organise transfer of relevant boxed records to Business Services, FACS The critical transition period runs from the GHSH tender announcement date to the full establishment of the new service providers on 1 November. By November, all records are required to be transferred to a continuing service provider or to archives. However, those organisations accessing the SSF may retain their records up until January 2016 and seek support to store them at that time. The Guidelines will be valid for that period. 1 Disposal refers to the processes related to the confidential destruction and the confidential and secure archiving and storage of records. 3
4 Description of client records and terminology What is a client record? Whilst the term client records is not all encompassing, it is best to consider the term broadly to cover any document that contains identifying information about a client. This includes both hard copy and electronic records and may include: Client intake sheets Diaries and booking sheets Journals and communication books Notes, whether handwritten or typed Correspondence Documents about the clients (both copies and originals) Database records (including Specialist Homelessness Information Platform (SHIP) or agency managed client information systems) Audio, dictation and video tapes Digital records Photographs, scans, images Particular attention should be paid to records containing sensitive information such as: Contact details Personal reference numbers Family history Medical history Financial history Personal memoirs, memories, recollections, reflections Confidential and personal disclosure Incriminating information about the clients Incriminating information about others Electronic records Records that are currently held in SHIP will be automatically copied to a new repository, CIMS. This will not affect accessibility, current record-keeping practices or archiving processes. It is possible for the organisation to continue to have direct access to their SHIP data, but this would require the organisation to enter into a separate licensing/hosting agreement with the SHIP/CIMS software vendor. Details of the activities and costs associated with doing this will depend on the exact needs of the organisation and would need to be worked out with FACS, the software vendor, and possibly the AIHW. The organisation's client records will continue to be held in CIMS, however, access to these is heavily restricted. If the organisation decided at some later date that access to this information is required then special arrangements would need to be made. Organisations need to manage their client records in accordance with contractual and statutory obligations detailed below. In order to satisfy those obligations, it may be necessary for the organisation to convert some data currently held only in SHIP into a physical record; either by printing the appropriate content or by arranging for a PDF based backup of the data to be made on CD. This can be achieved by contacting Infoxchange and by paying a nominal fee of $750. The GHSH Transition Guidelines contain further guidance. It will be possible, in future, for another service provider to access some information about the organisation's clients, in support of the streamlined access objectives of the GHSH reform, but only with appropriate client consent and subject to procedural controls. The items 4
that would not be accessible in this situation are the case management notes made by the original organisation, which require both client and source agency consent to access. Requests for this data will need to be directed to FACS so that arrangements to extract the information can be made where this is appropriate. Terminology 2 Sentencing is the examination of records in order to identify their category, required retention period and appropriate disposal action. Disposal refers to the destruction or archiving of records when they are considered to be no longer of use or are not required to be kept for legislative purposes. Records sentenced for destruction must be confidentially destroyed. 5 Legal and contractual obligations Retention of records The records of clients who have received a service from an SHS or NPAH provider fall within the parameters of the Health Records and Information Privacy Act 2002, Chapter 16A of the Children and Young Persons (Care and Protection) Act 1998, and the Privacy Amendment (Enhancing Privacy Protection) Act 2012. 3 Client records must be retained for seven years after the last delivery of service. In the case of minors under the age of 18 years, the records must be retained until the client has attained the age of 25 years. However, if a service provider is of the opinion that certain records must be kept for longer they should do so and advise FACS District of the circumstances. It is the responsibility of service providers to ensure that they meet their contractual and legal obligations regarding record keeping. Records must be stored in accordance with the relevant legislation. The storage must ensure security and confidentiality of the records. Records must be accessible to any client who seeks access to their information for the required time period. The Guidelines are to assist service providers with that process. Royal Commission into Institutional Responses to Child Sexual Abuse Given the ongoing Royal Commission into Institutional Responses to Child Sexual Abuse, providers should be aware of the requirements under section 6K of the Royal Commissions Act 1902 (Cth). This requires the retention of documents which may be required as evidence before the Commission and makes it an offence to destroy such documents. This would include case records of allegations or investigations of child sexual abuse matters or related documents. Such documentation should be retained beyond the required retention period on an indefinite basis. It is expected that service providers should be aware that a record falls within this category or should be able to use their experience, good judgement and discretion as to whether records fall within this category and label them for appropriate storage accordingly. Retention of Aboriginal clients records Providers are encouraged to retain the records of Aboriginal clients born before 1970 indefinitely. This is in recognition of their historical and cultural significance and reflects the recommendations of the Bringing Them Home Report of the National Inquiry in to the Separation of Aboriginal and Torres Strait Islander Children from Their Families. 2 Source: Hardcopy Records Disposal Procedures, Housing NSW. 3 The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Privacy Amendment Act) made many significant changes to the Privacy Act 1988. These changes commenced on 12 March 2014. 5
6 Consent to transfer records Consent to transfer records Where organisations are transitioning clients, consent for transfer of client records should be obtained from individual clients (see Attachment 3 of the Transition Guidelines: Client Transfer Consent Form). For active clients, consent should be obtained in all circumstances. For inactive clients, consent should be obtained where possible. Reasonable steps should be taken to obtain consent from all individuals whose records are held by the organisation. Exiting providers are required to provide FACS with a list of records that are being or have been transferred to another provider and details of the provider taking custody of them. Storage of records for which there is no consent to transfer Where consent has either been unable to be obtained or has been refused, then organisations that are closing or are ceasing to provide SHS/NPAH services are required to store records for the required timeframe. The storage must ensure security and confidentiality of the records. Records must be accessible to any client who seeks access to their information for the required time period. 7 Disposal of client records for which there is no consent to transfer Exiting organisations that have client records for which they have not been able to obtain consent to transfer and have no secure and confidential storage option available to them should consult with FACS District staff to identify the current status of the records and determine the best solution for their needs. If FACS agrees to store the relevant records on behalf of the service provider, it will take custody of records and store them at the Government Records Repository (GRR). Therefore, the service provider must follow these Guidelines to maintain consistency for tracking and retrieval purposes and to ensure that the processing of the records meets the standards and criteria set by GRR. Before records can be transferred into the custody of GRR, the service provider must process (this includes auditing, culling, and cataloguing) and prepare them for either destruction or storage. To assist with this process, FACS will organise for service providers to be supplied with: Numbered Type 1 archive boxes. This document (the Guidelines). Supporting Attachment 1 - Template for cataloguing records Please note, bar-coded labels with the service provider s unique identifier will be attached to each box once the boxes have been returned to FACS Business Services. 8 Steps for processing Service providers should audit all records and cull those that are no longer required to be kept under the legislation or for policy or evidence purposes. That is, they should cull records older than seven years with the exception of: - Minors records these should be kept for seven years from the last date of service or until the minor reaches the age of 25, whichever is later. - Records of Aboriginal clients born before 1970 these should be kept indefinitely. 6
- Records that may be used as evidence under section 6K of the Royal Commissions Act 1902 (Cth). This requires the retention of documents which may be required as evidence before the Commission and makes it an offence to destroy such documents. - Any other records for which the provider has sought and received legal advice that they require longer periods of retention or indefinite retention. It is the provider s responsibility to ensure they have sought any such advice. Cataloguing of records For the purposes of cataloguing all of the records that are boxed up for storage, records must be separated into categories. Attachment 1 (template for cataloguing records) provides a spread sheet to record this information as a main source of reference for the records and assist the retrieval of records in the future. Records should first be separated by record type: 1. Client files: these are individual files containing information about clients the catalogue for boxes containing these files requires detailed information to be recorded, including the names of all clients, date of birth, date they last received a service, and date when the file should be destroyed. 2. Other records: these are all other records e.g day books and diaries see Section 4 for more information. These records generally contain information about more than one client the catalogue for boxes containing these records require information about the date range of service information contained in them and the date of destruction. The records then need to be given a date for retention/destruction: 1. Records with a destruction date: Some records have a limited retention period (see Section 5) and need a destruction date recorded on the catalogue. 2. Records requiring indefinite retention: These also need to be clearly identified on the catalogue and placed in separate boxes. Step 1 Sentencing and categorising Service provider should examine each record and: - separate client files from other records - identify the retention periods Action required Records with more than one part are to be culled once all parts are together. Do not proceed with sentencing unless all parts are together. Note that the retention period of a record must be taken from the last action of the record (where there are multiple parts to a record the last action relates to the latest part). Ensure that details on the record have been finalised before applying a retention period or destroying the record. This involves checking the contents of the record to ensure there are no outstanding actions still to be completed. Inactive records which have not yet reached the end of their retention period should be marked with the month and year of the proposed destruction. For example, records to be destroyed in December 2015 should be marked in the MM/YYYY format (e.g. 12/2015 ). Calculate the destruction date of the box from the most recent action on the most recent records placed in the box. 7
If more than one child in a family group, calculate from the youngest child. Sort the records into categories for boxing - based on type (client file vs other records) and then based on destruction date. Sort records into alphabetical or numerical order within each group whichever is more appropriate. Within each category, sort the records according to due date for destruction. So there should be four groups for boxing: - Client files with a destruction date - Client files indefinite retention - Other records with a destruction date - Other records indefinite retention For those records that are to be destroyed (please refer to the section 5 and also note that records are to be kept for a period of seven years from the last access date), please indicate to be destroyed and the destruction date clearly on the front of each individual folder for each file to be destroyed. All folders containing records/files to be destroyed must be placed into the same box and clearly marked to be destroyed within the blue rectangle on the box. Use only black ink pen on record covers and boxes. Step 2 Confidential destruction of records Action required Ensure that the records have indeed passed their retention period. Ensure that records are no longer required under any other legislation and that all statutory or regulatory requirements have been fulfilled. Ensure that records are no longer required for policy or evidentiary purposes. Prepare records and organise for destruction. Sensitive records must be destroyed in a secure manner (ie shredding, pulping or placed in a security bin), as per legal obligations. If there are no means or access to secure destruction, prepare them for FACS to destroy. Catalogue and box as per step 1 above. Separate these boxes for destruction from the other boxes for archiving. There is no need to number these boxes. Ensure that there is documentation about which records have been destroyed. Before records are destroyed ensure that they are catalogued and that this catalogue is retained. Certificates of destruction should be obtained from any contractors used to destroy the records. Step 3 Boxing Action required Place the records for storage in Type 1 archive boxes. Do not over or under fill boxes. Recycled boxes cannot be used. FACS will provide you with sufficient Type 1 archive boxes. Records are to be placed in the box so that the spine of the record is on the base of the box. 8
Records are to be placed in the same direction in the box. All plastic and large metal pieces should be removed prior to placing records in boxes (eg lever-arch records, plastic continuous flow binders, plastic sleeve inserts etc.) Each box should be pre-numbered. If this is not the case, please number each box clearly within the blue rectangle, as shown below in Figure 1. Please note, the label shown in Figure 1 will be attached to each box by Business Services upon return. This label will be bar-coded and have a unique identifier for each provider. Do not place any markings other than the box number (if not already pre-numbered) in the blue rectangle as it is for use by FACS Business Services staff only. This is to allow for the appropriate label to be attached and for storage and shipment details to be entered. No other details should be marked on the box. Figure 1: Where to number each box on Type 1 archive box Step 4 Cataloguing of records Action required Records must be catalogued in the cataloguing template (Attachment 1). Populate the correct worksheet as appropriate: - Client files fill in all details as per Attachment 1, and ensure date of destruction or retain indefinitely is clearly indicated. - Other records - fill in all details as per Attachment 1, and ensure date of destruction or retain indefinitely is clearly indicated. Step 6 Transfer to FACS Business Services Action All boxes must be prepared in accordance with these Guidelines. Records must be properly culled and catalogued with all data correctly entered into the cataloguing template. FACS Business Services will not check contents of boxes for accuracy in culling procedures. Service provider should ensure that this is done accurately. FACS Business Services will make random checks of system details and box contents. 9
Any problems will be referred back to the service provider for correction. It is the responsibility of the service provider to ensure that records have been culled according these Guidelines and that the data have been entered accurately. It is the responsibility of the service provider to arrange for pick-up and delivery of their boxes to FACS Business Services. The service provider is also responsible for all costs associated with transporting the boxes to FACS Business Services. The Service provider is to use Toll Priority Couriers to ship the boxes to FACS Business Services. If you require the details of Toll Priority Couriers, please contact FACS Business Services by sending an email to: records-liv@facs.nsw.gov.au or on: 02 9765 3751. Please instruct Toll Priority Couriers to deliver the boxes to: Linda Trovato Records Coordinator FACS Business Services Department of Family and Community Services Level 5, 23-31 Moore St, Liverpool 2170 The completed Catalogue of Records template (Attachment 1) should be sent to: records-liv@facs.nsw.gov.au Service providers should discuss these Records Guidelines and any queries they have in relation to the disposal of client records for which there is no consent to transfer with their FACS District staff member. 10