Utah Department of Administrative Services

Division of Archives & Records Service

Box Elder County (Utah). Pioneer Care Center

5291--Court ordered community service records
5313--Summer youth employment personnel records
5318--Employee time cards
5323--Accounts payable records
5324--Patients' bank statements
5328--Laundry inventories
5334--Patient financial case files
5349--Incident reports
5357--Cash receipts
5361--Payroll printouts
5159--Job application forms non-hired
5160--Fire protection planning records
5163--Accident and injury records
5165--Quarterly wage report
5176--Nurses' aides registry releases
5177--Supervisors meeting minutes
5198--County personnel requisition and analysis records
5201--Employee locker security records
5215--Personnel case files
5228--Green Thumb Program case files
4255--Nursing home deaths monthly reports
4258--Depreciation records
4261--Fire protection equipment records
4745--Hill-Burton uncompensated care program subject files
4748--Hill-Burton community service assurance reports
4755--Medicaid nursing home provider contracts
4756--Medicaid administrative subject files
4760--Veterans administrative records
4776--Cash deposit reports
4777--Patient pharmacy ordering records
4791--Recovery services records
4792--Service contracts and agreements
4802--Audits
4803--Employee schedules
4299--Insurance records
4306--Sanitation inspection monthly reports
4318--Daily meal census worksheets
4322--Board of Directors information records
4336--Board of Directors minutes
4338--Insect control reports
4344--Health care provider contracts
4345--Staffing reports
4349--Medicare rate guidelines
4350--Licensing records
4354--Nursing home reports
4356--Commodity program files
4461--Medicare billing case files
4469--Facility cost profile report
4471--Medicare cost report
4238--Monthly expenditure report
6654--Pharmacy bills
6663--Insurance claims denied
6668--Staff committee minutes
6670--Policy and procedure files
6671--Community Development Block Grant unsuccessful applications
6672--Expense report
6673--Patient care review records
7705--Policy and procedure manuals
6547--Patient case files
6548--Monthly medical charges
6549--Charge slips
6551--Pharmacy quarterly report
6552--Daily observation notebooks

AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5291
TITLE: Court ordered community service records
DATES: i 1985-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These records document participation in court ordered community service projects. A district, circuit, or juvenile court may order the completion of a specific number of hours of community service in lieu of a jail term. The Pioneer Memorial Care Center provides supervision of criminal offenders undertaking community service projects at the center. The files include an introduction form (contains name, number of hours of community service ordered to perform, by which date, and any expectations); a sheriff's form (contains name of program coordinator, date, name of client, agency, phone number, contact person, number of hours ordered to perform, beginning date, hours completed, type of work, days and hours worked, total hours); a copy of the court order; and time card.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 1 year after completion of community service and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office. The courts maintain the record copy of these files.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5313
TITLE: Summer youth employment personnel records
DATES: i 1986-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These records document participation in the summer youth program. The summer youth program provides employment with government agencies for youth between the ages of 14 and 18. The Bear River Association of Governments (BRAG) distributes money to participating local agencies. These files include time cards; BRAG form (employee's name, social security number, home address, hours worked, signature of supervisor, date, work site, and phone number); related correspondence; application for employment (name and address, phone number, positions applied for, date able to start, whether previously worked for Box Elder County, highest grade completed, any disability which would interfere with performance of duties); copies of office of labor and training/modification form (contract number, authorized representative, participating agency, date contract effective, ending date, occupation, name, days active, hours per week, wage per hour, total wages, workman's compensation code, total contract code, terms participating agency agreed to, signatures of contracting and participating agencies and youth supervisor).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years after termination of employment and then destroy.

APPRAISAL

Administrative

This disposition is based on the agency's administrative needs. The federal government does not specify any retention period for these records, but similar programs usually indicate a three-year period.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5318
TITLE: Employee time cards
DATES: i 1970-
ARRANGEMENT: Chronological, thereunder alphabetical by employee name
ANNUAL ACCUMULATION: 1.00 cubic foot.

DESCRIPTION: These are time cards stamped by a time clock as an employee begins and ends each work day. They document the number of hours worked and are used to create the center's payroll. The cards include the pay period, card number, name of employee, total hours worked, signature of employee, stamped date, time in and out, and handwritten notations totalling hours worked.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the agency and reflect the provisions of the 1990 Utah State General Retention Schedule (schedule 10, item 25) and the Utah Municipal General Records Retention Schedule 1990 (schedule 8, item 14).


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5323
TITLE: Accounts payable records
DATES: i 1974-
ARRANGEMENT: Chronological, thereunder alphabetical by vendor name
ANNUAL ACCUMULATION: 1.00 cubic foot.

DESCRIPTION: These files document payment for goods and services received by the care center. They are audited. They include copies of the request for payment form (date, department name and code, vendor name and address, purpose of payment and amount, signature of county auditor and department head and date of payment); copy of bill; receipts; purchase orders, and check stubs.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 4 years and then destroy.

APPRAISAL

Fiscal

This disposition is based on the fiscal needs expressed by the center's administrator. This disposition also reflects the 1990 Utah State General Retention Schedule and the Utah Municipal General Records Retention Schedule 1990.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5324
TITLE: Patients' bank statements
DATES: i 1980-
ARRANGEMENT: Chronological, thereunder alphabetical by patient name

DESCRIPTION: These are bank statements for fiduciary accounts for care center patients. The center cannot hold more than $50 for a patient without placing the funds in an interest bearing account. The center receives this monthly statement to determine the amount of money in the accounts. The center compiles a quarterly report for the patient. Under Medicare requirements a patient may only maintain a savings account of less than $2,000. The statements include the statement date, account number, and all withdrawals and deposits.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy.

APPRAISAL

Fiscal

This disposition is based on the administrative needs expressed by the office.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5328
TITLE: Laundry inventories
DATES: i 1980-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: This is a biweekly laundry inventory. It is used to compile reports. The study includes machine, description of load (including the contents of load), number of pounds, and totals (nursing home totals and residence personal clothing totals).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 1 year and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative need expressed by the center.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5334
TITLE: Patient financial case files
DATES: i 1986-
ARRANGEMENT: Alphabetical by patient name

DESCRIPTION: These files document patients' financial conditions and expenses incurred at the Pioneer Care Center. They are used to create billings for provided medical services. Until 1990, these files were combined with the patients medical files at the discharge of the patient. They are now maintained separately.

The files include the health care facility admittance record (patient's name, usual residence, case number, race, marital status, date of birth, age, social security number, birthplace, citizenship information, Medicare/Medicaid number, date and time admitted, physician's name, admitted from, how transferred, referred by, name, and address and phone number of next of kin, name of person responsible for account, relationship, occupation and employer's name and address, phone number and name of local funeral home desired, informant's signature, witnesses's signature, signature of patient, signature of responsible party, and a insurance release statement).

The files also include an insurance card copy; utilization review committee form (patient's medical record, age, sex, admission date, admitted from, number of days in acute hospital, reason for admission, admitting diagnosis, current diagnosis, patient's condition since admission, current condition, skilled care needs, signature of reviewing physician, signature of Utilization Review Committee, and date); payment contracts; admission checklist; notifications on eligibility to receive Medicaid; explanation of Medicare benefits; correspondence; quarterly statement of personal money needs; and statement of acknowledgment.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years after discharge or death of patient and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the center and the statute of limitations provisions concerning malpractice. "No malpractice action against a health care provider may be brought unless it is commenced within two years after the plaintiff or patient discovers, or through the case of reasonable diligence should have discovered the injury, whichever first occurs, but not to exceed four years after the date of the alleged act, omission, neglect or occurrence" [Utah Code Annotated 78-14-4.4 (1990)].


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5349
TITLE: Incident reports
DATES: i 1989-
ARRANGEMENT: Chronological, thereunder alphabetical by type of incident
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are reports of all patient incidents occurring at the Pioneer Care Center (medications, slips, falls, etc.). They are used to create reports for state regulatory agencies and for investigative purposes. Each incident is investigated by the center's Safety Committee to determine cause and to correct any existing problems. They include the incident report log (number, patient, name, date of incident, date received by safety committee) and the incident report (patient's name, name of patient's physicians, cause for hospitalization, condition before incident, employee visitor, or other; statement and description of incident by person involved; name and addresses of witnesses; description of incident; was person involved seen by a physician, date and time, statement and signature of examining physician, indication of whether x-rays were taken, date and signature of Safety Committee reviewing case).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years or until resolution of all litigation and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on the administrative needs expressed by the center and the statute of limitations for malpractice actions. "No malpractice action against a health care provider may be brought unless it is commenced within two years after the plaintiff or patient discovers, or through the case of reasonable diligence should have discovered the injury, whichever first occurs, but not to exceed four years after the date of the alleged act, omission, neglect or occurrence" [Utah Code Annotated (UCA) 78-14-4.4 (1990)].


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5357
TITLE: Cash receipts
DATES: i 1980-
ARRANGEMENT: Numerical by receipt number
ANNUAL ACCUMULATION: 0.50 cubic feet.

DESCRIPTION: These are receipts issued for monies received by the care center to document all payments made. They include receipt number, date, received by, amount, purpose of payment, form of payment (cash, check, or money order), and signature of person issuing receipt.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy.

APPRAISAL

Fiscal

This disposition is based on the administrative needs expressed by the office and the 1990 Utah State General Schedule and the Utah Municipal General Records Retention Schedule 1990.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5361
TITLE: Payroll printouts
DATES: i 1984-
ARRANGEMENT: Numerical by employee number
ANNUAL ACCUMULATION: 0.50 cubic feet.

DESCRIPTION: This is a biweekly computer printout of the center's employee payroll. It is used for reference purposes. It includes employee number, name, regular hours, amount paid, total paid, taxes withheld, other deductions, net pay, and check number.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 3 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office. The county auditor maintains the record copy of all payroll reports.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5159
TITLE: Job application forms non-hired
DATES: i 1989-
ARRANGEMENT: Alphabetical by applicant name
ANNUAL ACCUMULATION: 0.20 cubic feet.

DESCRIPTION: These are application forms completed by persons seeking to work at the Pioneer Memorial Care Center, but who were not hired. They are maintained on file for one year and are considered for other similar positions that become vacant. The form includes the date of application, position applying for, name, address, and telephone number of applicant, questions whether applicant is under eighteen, an American citizen, has previously made application or worked for the care center, whether applicant had previously been convicted of a felony, whether a veteran, notes of interviewer, positions considered, employment history, special skills and qualifications, education, and applicant's signature.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 1 year and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office and reflects their long standing policy.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5160
TITLE: Fire protection planning records
DATES: i 1976-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: This is an informational file on fire prevention. It is used for reference purposes. This file contains information on fire extinguishers [application (type), contents, how to use, range and duration], fire safety plan (for posting), copies of smoking permitted and no smoking signs.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office until information is updated and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5163
TITLE: Accident and injury records
DATES: i 1974-
ARRANGEMENT: Chronological, thereunder alphabetical by type of incident
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These files document on-the-job injuries and illnesses of Pioneer Care Center employees. The files include the Bureau of Labor Statistics log and summary of occupation injuries and illness (containing the company name and address, case number, date of injury, illness, employee's name, occupation, department description of injury or illness, totals from previous page, fatalities, and injuries with lost work days); the Industrial Commission first report of injury form; a copy of employee's index (claim number, reference number, date of accident, type of injury, and name of injured, name of facility and policy number); and various Occupational Safety and Health Administration (OSHA) brochures and pamphlets.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the record's primary value to the care center and reflects a previously approved retention for the 1990 Utah State General Schedule.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5165
TITLE: Quarterly wage report
DATES: i 1985-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are reports submitted to the Department of Employment Security. They include the quarterly wage list (the name and address of employer, registration number, quarter ending date, employee social security number, name of employee, hire date of new employees, total wages for quarter, page totals and grand totals), and the reimbursable employment, payrolls and new hires report form (name and address of organization, noninsured workers, year first quarter, individual amount (total noninsured employment, noninsured payroll, noninsured new hires) for the first, second, third, and fourth quarters, insured worker's name and department of person completing form, and telephone numbers).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 3 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office. The Utah Department of Employment Security maintains the record copy of these reports.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5176
TITLE: Nurses' aides registry releases
DATES: i 1989-
ARRANGEMENT: Alphabetical by employee name

DESCRIPTION: These releases allow the care center to release information on nurses' aides through the nurses' aides registry. The registry was created in 1989 as part of a larger effort, the National Health Practitioner Data for Adverse Information, to report both training and any adverse information concerning nurses' aides [45 Code of Federal Regulations (CFR) 60 (1989)]. The registry is used by prospective employers to guard against hiring abusive or unqualified medical personnel. These release forms include an explanation of training completed by each nurses' aide. The forms have either been signed and dated, or the nurses' aide has written a statement refusing to be placed on the registry.

RETENTION

DISPOSITION

.

FORMAT MANAGEMENT

Paper: Retain in Office until termination and then place in personnel file.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office. Neither federal nor state guidelines have been located to provide specific guidelines.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5177
TITLE: Supervisors meeting minutes
DATES: i 1988-
ARRANGEMENT: Chronological

DESCRIPTION: These are the minutes of the monthly supervisor's meetings. They are used for reference purposes. This is the posting copy which is placed in the staff area for all employees to read. They include the date, time, names of persons present and those excused, summary of proceedings, issues discussed, report of other meetings attended, clarification of new policies and procedures, and time of adjournment.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 1 year or until administrative need ends and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the care center. These are not the official copies, but only duplicates maintained for reference purposes.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5198
TITLE: County personnel requisition and analysis records
DATES: i 1988-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.20 cubic feet.

DESCRIPTION: County personnel requisitions are two-part forms completed by all Box Elder County departments. They are used to fill vacant positions and to request new positions. The original copy is submitted to the county personnel office, while a copy is maintained by the submitting office for reference purposes. The form includes position title, whether exempt or nonexempt, grade, step, classification, part- or full-time, replacement or new position, reasons for replacement, requesting department, whether county employees will be considered for position, educational requirements, specialized training and experience required, and a section to be completed if requesting additional personnel (special functions, how those functions are currently being performed, why position is required, and signature of department head or elected official).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 2 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the care center. The county personnel office maintains the record copy of these records.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5201
TITLE: Employee locker security records
DATES: i ca._1984-
ARRANGEMENT: None
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: This file documents the assignment of lockers and combination locks to employees. It includes log sheets (containing locker number and name of employee), a control chart, and cards listing the serial numbers of all locks and combinations.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office until list updated or locks replaced and then destroy.

APPRAISAL

Administrative

This disposition is based on the record's primary administrative value as expressed by the office.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5215
TITLE: Personnel case files
DATES: i ca._1963-
ARRANGEMENT: Alphabetical by employee name
ANNUAL ACCUMULATION: 0.50 cubic feet.

DESCRIPTION: These are the official personnel files of all Pioneer Care Center employees. The files include the employment application, notices of personnel action, new hire forms, pay change, separation information, signatures, employee evaluation forms, preemployment physical form, W-4, leave requests, orientation meeting form, employment performance appraisal, employment eligibility verification, commendations, letters of resignation (where applicable), insurance coverage forms, direct deposit forms, military leave, educational certificates, and may include disciplinary action forms.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 30 years after termination or until three years after retirement and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the center's administrator and the previously approved 1990 Utah State General Retention Schedule (schedule 11, item 2) and the Utah Municipal General Records Retention Schedule 1990 (schedule 9, item 12).


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 5228
TITLE: Green Thumb Program case files
DATES: i 1986-
ARRANGEMENT: Chronological, thereunder alphabetical by employee name
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These files document the care center's participation in the Green Thumb Program. This is a program designed to improve the economic and social conditions of older Americans and rural communities in providing essential community services and promoting the employment and training of older Americans. The Green Thumb Program is sponsored by the National Farmers' Union and is funded by the U.S._Department of Labor. Participants are low income persons 55 years and older who work an average of 20 to 24 hours per week and are paid directly by the program. The care center receives no funding for participating.

The files include time cards (pay period, dates, times in and out); Green Thumb employment form (enrollee name, address, job title, social security number, beginning and ending dates, contributor's name and address, phone, county, type of project, nature of work, date, number hours worked plus holidays, sick hours, classification of in-kind supervision hours, supervisor's initials, total hours of supervision multiplied by rate of pay and total, other itemized costs, cost contribution and amount totals, worker's signature, and supervisor's signature); time sheets (county, name, address, social security number, phone, host agency address, phone number, enrollee's signature hours worked, sick hours, personal leave, totals, enrollee change of address, any change in work schedule, enrollee's and supervisor's signatures); performance review form (name, date, job title, review of performance, and host agency comments); enrollee job description; work schedule; medical examination form; memoranda; and surveys.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years after final expenditure report submitted and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on federal requirements expressed in 29 CFR 89.54 (1990) which provides that "each grantee shall retain for a period of at least three years all financial records, supporting documents, statistical records, and all other records pertinent to the project."


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4255
TITLE: Nursing home deaths monthly reports
DATES: i 1984-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are monthly reports submitted to the Bear River District Health Department for the State Division of Vital Statistics of all deaths occurring at the care center. The report includes name and address of nursing home, date, period covered by the report, date of death, name and age of deceased, name of medical attendant, and name of funeral home or name of person acting as funeral director.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 1 year and then destroy.

APPRAISAL

Administrative

This disposition is based on the needs expressed by the office to determine that reports were submitted.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4258
TITLE: Depreciation records
DATES: i [ca._1963-]
ARRANGEMENT: Chronological

DESCRIPTION: These records document the depreciation of the center's building equipment. They are used for all audits. They include the invoice of depreciation (contains date, name of department, fund, object code, vendor name and address, delivery instructions, item being billed, unit cost, actual cost, signature of county auditor or deputy auditor and commission chairman), copies of purchase orders, and depreciation schedules [building, acquired amounts, cost life, depreciation (prior and current) of furniture and equipment].

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy provided current information is transferred.

APPRAISAL

Administrative Fiscal

This disposition is based on the administrative needs expressed by the center's administrator.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4261
TITLE: Fire protection equipment records
DATES: i 1981-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These records document the operational condition of the center's fire protection systems (e.g._sprinklers, fire alarms). The files include correspondence, copies of inspections of facilities and equipment, certificates of flameproofing of linen, copies of fire regulations, and copies of boiler inspection and permit. The kitchen system is inspected semiannually. There is also a small file on fire damage which occurred in one room in 1985 containing receipts and invoices on the repair of the facility.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the records primary value to the center as expressed by the administrator.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4745
TITLE: Hill-Burton uncompensated care program subject files
DATES: i 1975-
ARRANGEMENT: Alphabetical by subject, thereunder chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These files document participation in the Hill-Burton Uncompensated Care Program. The Hill-Burton Act was enacted to provide federal assistance to communities for the construction and modernization of health care facilities. Each medical facility receiving program funds must provide annually a reasonable volume of services to persons unable to pay for those services. Uncompensated services means "services which are made available to persons unable to pay therefor without charge or at a reasonable cost of such services" [42 Code of Federal Regulations (CFR) 53.11(6)(1989)]. The Pioneer Memorial Care Center was constructed with Hill-Burton Act funds.

These files include the Box Elder Plan for providing uncompensated nursing home care 1980; copies of state and federal rules and regulations; Utah Fact Sheet Financial Assistance, 1946-1971; related correspondence; Notice of availability of Free Nursing Home Care; computation charts; providers guide; Program Notices; inactive applications for uncompensated services (containing name, address, phone, occupation, employer, gross family income for last three months, and total income for last twelve months, family size (names and relationships), date and signature); and attached authorization calculation sheet (includes income, whether eligible for no-pay or part-pay, or ineligible, date and signature of person determining eligibility, and date applicant provided a copy of application).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 10 years and then destroy provided litigation, claims, negotiations are resolved.

APPRAISAL

Administrative Legal

This disposition is based solely on the administrative needs expressed by the center's administrator. Though the Center's has legally satisfied federal requirements expressed in 42 CFR 124.510(b)(1989), it would like to maintain the records for an additional 10 years.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4748
TITLE: Hill-Burton community service assurance reports
DATES: i 1980-
ARRANGEMENT: Chronological

DESCRIPTION: These are copies of the triennial report required to be submitted to the Department of Health and Human Services by 42 Code of Federal Regulations (CFR) 124.509 (1989). The reports provide assurances that the facility will serve patients from the community without regard to race, age, or ability to pay. This policy is a condition for receiving federal assistance through the Hill-Burton Act for the construction and modernization of health care facilities.

The report includes the identification number; name and address of facility; fiscal year end; type of facility; change in status (yes/no), if yes, transfer of status change; primary geographic area served; governmental third party payer programs (Medicare, Medicaid); and existence of organized emergency rooms; number of admissions; length of operations; number of patients that stayed in facility previous night; questions on type of case; number of Veterans Administration patients; number of Black residents, Hispanics; number per age category; signature of administrator, and date report was completed.

RETENTION

Retain 4 years.

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 4 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the center. The Department of Health and Human Services does not specify any retention period. The center wants to maintain for one year after subsequent report has been submitted, for a total of 4 years.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4755
TITLE: Medicaid nursing home provider contracts
DATES: i 1973-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These contracts between the U.S._Department of Health and Human Services, the Utah Division of Health Care Financing, and the Pioneer Memorial Care Center are required for participation in the Medicaid program. Under these agreements the health care provider agrees to limit charges and to comply with specific Medicaid requirements [42 Code of Federal Regulations (CFR) 489.20 (1989)]. The term of the contract is 12 months, and it is renewed annually. The contract includes the name, address, and type of institution; general provisions of the contract; signature of the director of the Division of Health Care Financing; date; signature of provider (administrator and date); health insurance benefit agreement (provider number, name and address of facility); accepted signature for provider and date; accepted signature for the Secretary of Health and Human Services and date; and related correspondence.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years and then destroy.

APPRAISAL

Administrative Historical

This disposition is based on the administrative needs expressed by the administrator and the provisions of 42 CFR 489 (1989) which indicate that the records should be maintained for 3 years.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4756
TITLE: Medicaid administrative subject files
DATES: i 1977-
ARRANGEMENT: Alphabetical by subject, thereunder chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These files document the Pioneer Care Center's administrative participation in the Medicaid program. They include copies of Medicaid newsletters, related correspondence on the administration of Medicaid monies, memoranda, policies and procedures, guidelines, and interim rates.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years or until information is updated or superseded and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the care center.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4760
TITLE: Veterans administrative records
DATES: i 1987-
ARRANGEMENT: Alphabetical by subject, thereunder chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These records document the process of providing service to veterans. The Veterans Administration has contracted with the Pioneer Memorial Care Center to provide service to veterans residing in its service area. The files are used for reference purposes. They include correspondence, policies, and agreements between the Veterans Administration and the care center (includes name, address of facility and veterans office, signature of contracting agencies, general provisions, and taxpayer identification number).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 4 years after expiration of contract and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4776
TITLE: Cash deposit reports
DATES: i 1987-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are reports on all cash bank deposits submitted biweekly to the county auditor. They are used for accounting purposes. They include a cash register tape with handwritten notations referring to source on cash form (date, number of report, signature of county auditor and treasurer, number of checks, deposit number, and total amount).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 1 year and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office. The county auditor maintains the record copy of these records.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4777
TITLE: Patient pharmacy ordering records
DATES: i 1987-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These records document the ordering of drugs for individual patients. The files include an internal delivery sheet (name of patient, name of facility, date, nurses signature, formula, method of delivery of medication, comments); Healthwise Services packing list (date, name of patient, description, quantity, prescription number); and request for payment forms (department, name, department code number, vendor, purpose for payment, amount, discount, total, and signature of department head).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 4 years or until resolution of any litigation and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office. The record copy of all prescribed medications is filed in the patient's case file.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4791
TITLE: Recovery services records
DATES: i 1988-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These files document the collection by the Division of Health Care Financing of Medicare overpayments made to nursing home patients receiving care at Pioneer Care Center. The Division of Health Care Financing acts as collector under a contract with the Office of Recovery Services. The files include correspondence and a form listing patient name and number, month of service, amount of Medicare overpayment owed to ORS, Medicare Information Bulletins, cancelled checks, and nursing home claim exemption forms.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 5 years after resolution of litigation or claim and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the care center. The Division of Health Care Financing maintains the record copy for 9 years and ORS maintains their copy for 5 years. 42 Code of Federal Regulations (CFR) 455 (1989) requires the state to investigate complaints of Medicaid fraud or abuse, but does not specify how far back in time the agency can investigate. According to the Denver Regional Office of the Federal Care Financing Agency, the government has 3 years in which to audit these records.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4792
TITLE: Service contracts and agreements
DATES: i 1979-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are contracts and agreements documenting services provided to the Pioneer Care Center. They include affiliation agreements, contracts with medical consultants and therapists, social services agreements, shared services purchase agreements, emergency housing and hospital transfer agreements.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 4 years after expiration of contract and then destroy.

Paper copy: Retain in Office until expiration of the contract and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on both the record's legal requirements and the administrative needs of the center. The four year retention after the expiration of the contract is mandated by the state's statute of limitations provisions for property contracts (other than those relating to real property) in Utah Code Annotated (UCA) 78-12-25 (1990).


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4802
TITLE: Audits
DATES: i 1975-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are annual audits by external auditors of the Pioneer Care Center's financial condition. They include combined statements, financial statements of individual funds, a balance sheet, and recommendations for improved financial operations. From 1975 to 1985, the center had separate audits. From 1986 to 1989, the audit results were included in the Box Elder County combined audit. In 1990, the center will again be audited separately.

RETENTION

DISPOSITION

Transfer to the State Archives with authority to weed.

FORMAT MANAGEMENT

Paper: Retain in Office for 10 years and then transfer to State Archives with authority to weed.

APPRAISAL

Administrative Historical

This disposition is based on Utah County General Records Retention Schedule, Schedule 13, Item 6.

This disposition is based on the record's primary administrative and fiscal value to the agency and its secondary historical value to researchers.

PRIMARY DESIGNATION

Public


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4803
TITLE: Employee schedules
DATES: i 1986-
ARRANGEMENT: Alphabetical by department
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These schedules are used to schedule employees, to staff adequately all work shifts with full-time and part-time employees, and to create staffing reports. They include pay period, department, month, date, year, employee name, day of week and date, work schedule per day including any scheduled leave (vacation, holiday).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 1 year and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the agency. The schedules have no value after staffing reports have been compiled.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4299
TITLE: Insurance records
DATES: i 1974-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These records document the administration of fire, liability, malpractice, and worker's compensation insurance. They are used for reference purposes. Since 1978, Box Elder County has administered the center's insurance and the County Auditor has maintained the record copy of all insurance materials. The center's files are only duplicates.

The files include request for payment forms, copies of insurance billings, copies of policies (not official copies), insurance breakdown report (showing expenses for fire, boiler, data processing monies), directives, check stubs from the Utah State Insurance Fund, receipts submitted from the center to the state, employer's payroll and premium report.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 8 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the needs expressed by the center's administrator.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4306
TITLE: Sanitation inspection monthly reports
DATES: i 1985-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are monthly inspection reports completed by a private company on the dishwashers and laundry facilities to guarantee detergents and water temperatures meet established standards for sanitation purposes. They are used to compile an annual report. They include account, address, name of representative, results before service, products in use, machine controls, mechanical operation, operating procedures, employee training, supply order, and comments.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 1 year and then destroy.

APPRAISAL

Administrative

This disposition is based on the needs expressed by the center's administrator.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4318
TITLE: Daily meal census worksheets
DATES: i 1984-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.20 cubic feet.

DESCRIPTION: These worksheets are compiled by the center's dietician. They are used to create commodities reports. They include an accounting of number of meals served to patients. The report is separated into the following patient categories: private, Medicaid, Medicare, veterans, jail inmates and others (breakfast, dinner, and supper).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 4 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the agency. The records have no value after the commodities report is compiled.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4322
TITLE: Board of Directors information records
DATES: i 1963-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These records document the activities of the Pioneer Care Center's Board of Directors. In 1963, the Board of Directors was organized as the governing board of the Pioneer Memorial Care Center. In 1980, the Box Elder County Commission took direct control of the center and the board became strictly advisory. The files include copies of the original and corrected bylaws; related correspondence; certified mail receipts; member orientation information; description of the responsibilities of the Board of Directors; and lists of board members.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years or until administrative need ends and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office. The record copies of the bylaws are maintained with the minutes which are permanent.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4336
TITLE: Board of Directors minutes
DATES: i 1963-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.20 cubic feet.

DESCRIPTION: These are the official minutes of the Pioneer Memorial Care Center's Board of Directors. In 1963, the board was created as the center's governing board, but in 1980 the board became strictly advisory. The files include agenda, minutes, and bylaws. The minutes contain date, time, place of meeting, names of directors present and absent, summary of proceedings indicating motions discussed, passed and failed, reports, finances, and time of adjournment.

RETENTION

Retain permanently.

DISPOSITION

Retain in agency custody.

FORMAT MANAGEMENT

Paper: Retain in Office permanently.

Paper copy: Retain in Office for 1 year or until administrative need ends and then destroy.

APPRAISAL

Administrative Historical

This disposition is based on the administrative needs expressed by the office and the historical value of these records to document the actions of the Board of Directors.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4338
TITLE: Insect control reports
DATES: i 1977-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are completed report forms documenting the extermination of insects. They are used to compile annual facility reports. The files contain the Mosquito and Fly Abatement District Report. The report includes date and time, name of operator, license number, work location, authorization, areas treated, method chemicals applied, rate applied, remarks, work completed by signature, date and total cost.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 2 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the records primary administrative value to the agency as expressed by the center's administrator.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4344
TITLE: Health care provider contracts
DATES: i 1979-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are agreements between the state of Utah and Pioneer Care Center by which the care center agrees to abide by the requirements of the Medicare program in order to receive Medicare funding. As a condition of participation in certification or recertification, these agreements are required by 42 Code of Federal Regulations (CFR) 431.107 (1989), and are renewed annually.

The files include correspondence from the Division of Health Care Financing, signed and approved contracts, and ownership disclosure forms. The ownership disclosure form is required to be part of the certification process for all facilities participating in the Medicare program by 42 CFR 442 (1989).__It includes the following information:__name and address of the facility, provider number, vendor number, contract number, city, state and zip code, phone number, indication of whether the care center is government operated or a chain affiliation, type of facility, and names and addresses of individuals having direct or indirect ownership of facility.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years and then destroy.

APPRAISAL

Administrative Legal

This retention is based on the needs expressed by the administrator and the provisions of 42 CFR 405.1101-405.1137_ (1989) which indicates that "in the absence of a state statute records should be maintained for 5 years." The State maintains its copies for 6 years.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4345
TITLE: Staffing reports
DATES: i 1980-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are quarterly reports submitted to the Utah State Health Bureau of Facility Review to show that the facility maintains adequate staffing at all times. These reports are required by 42 Code of Federal Regulations (CFR) 431.610(g)(1)(ii)(1989). These reports include the Report on Consultants, Report on Other than Nursing Personnel, and Report on Nursing Personnel-Supplementary Page. Information within the reports includes the name and address of the facility, report date, reporting period, name of the employee or consultant, employee's position or the consultant's area of consultation, number of hours worked by the employee or consultant, and a signed certification by the facility administrator that the information submitted is correct and that all standards are being met.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on the record's primary administrative and legal values to the agency. These reports are subject to federal review per 42 CFR 431.610(f)(4)(1989). The review period is three years according to the Denver regional office of Medicaid.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4349
TITLE: Medicare rate guidelines
DATES: i 1979-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These files document notifications received on Medicare rate increases. They are used to calculate charges to Medicare patients. The files include the notice (containing methodology of applying rate, facility name, new rate for both skilled nursing (SNF) and intermediate care facilities (ICF-1, ICF-2); property differential, and nursing incentive), Utah Medicare Nursing Home Prospective Rate Calculations, tables to determine maximum staff hours, and handwritten calculation tallies on the various methods of tallying charges.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years after rate change and then destroy.

APPRAISAL

Administrative

This disposition is based on the needs expressed by the office.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4350
TITLE: Licensing records
DATES: i 1977-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These files document the issuance of licenses to the Pioneer Care Center. All nursing facilities are required annually to become licensed [Utah Code Annotated 26-21-8 (1989)]. They include request for payment form (department name and code, date, name of vendor, purpose of payment, approval, signature for auditor or deputy auditor, signature of department head), correspondence with the Utah Division of Community Health Services, memoranda for license, certified mail receipts, request for agency action/license application [file number, name of applicant, name of facility, license period, action requested (annual renewal or new application), type of facility, identifying information (name of facility, address, phone number, name of administrator), number of beds, units, and stations (per type--hospital, nursing care facility, residence care facility, or ambulatory surgical center); ownership information, and certification of understanding with the signature of administrator and date mailed.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 4 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the needs expressed by the office. These licenses are renewed annually and are rarely used after expiration. No retention guidelines are provided by the State Health Department. The State maintains their copies permanently.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4354
TITLE: Nursing home reports
DATES: i 1967; 1977-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These are annual reports submitted to the State Bureau of Health Facility Licensure. "Qualified personnel" are required to perform on-site inspections at "least once during each certification period" by 42 Code of Federal Regulations 431.610(g)(3)(1989). They include related correspondence and the report form [nursing home name, address, phone, name of administrator, number of Medicare certified beds, classification, ownership and operation, bed complement (status and changes from previous year), utilization (added in 1989), census, number of admissions, number of discharges, number of deaths, census ending December 31, number of transfers, patient care, type of nursing personnel; age and sex of patients; services provided; medical and social system linkages; services to nonresidents, geographic service area, and the signature of administrator]. Prior to 1980, inspections were completed biannually with a report written by the Division of Health Inspections. This report included the name of the nursing home, name of licensed operator, address, and inspection evaluations on individual aspects of the nursing home's physical facilities and food services.

RETENTION

Retain 3 years.

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the needs expressed by the Center's Administrator. The report is completed annually and is used only for comparison purposes. The State Bureau of Health Facility Licensure maintains these reports permanently as part of their licensing files.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4356
TITLE: Commodity program files
DATES: i ca._1965-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These files document the use of U.S._surplus food received through the U.S._Department of Agriculture (USDA) Commodity Program. The files include a questionnaire for charitable institutions, correspondence with the Utah Department of Human Services, Division of Administrative Services; monthly inventory report (name of institution, authorized year, and signature); USDA Commodities Order form (name of institution, number and address; pick-up date and items ordered); monthly commodity report (commodity, beginning inventory, amount received, amount used, ending inventory, number served at institution by each age group, total number of needy served, non-needy served, and total number served).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years after close of fiscal year which records pertain and then destroy provided all claims resolved and audits completed.

APPRAISAL

Administrative Legal

This disposition is based on the provisions of 7 Code of Federal Regulations (CFR) 250.16(5)(b) (1990) which specifies a retention of "3 years after close of fiscal year which records pertain", and also on the needs expressed by the center's administrator.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4461
TITLE: Medicare billing case files
DATES: i 1984-
ARRANGEMENT: Chronological, thereunder alphabetical by patient name
ANNUAL ACCUMULATION: 0.50 cubic feet.

DESCRIPTION: These files document the actual billings submitted to Medicare and payments received for services rendered to patients covered by Medicare. The care center bills Medicare for the total amount owed. There are two types of billings. Medicare A are billings for patients transferred from hospitals, and Medicare B are billings for patients receiving only physical therapy.

Both types of files include a receipt to Medicare (including receipt number, date, amount received, purpose of payment, form of payment and signature); a check stub for Medicare payment (includes provider number, date, and amount); a computer printout of a detailed spread sheet of all charges (includes date of payment, page number, bill number, date of service, batch number, and totals); copies of the institution's patient billings (includes patient's name, home address, and date of birth, date of admission, and dates of service, description of expenses, services, and totals, Medicare payments, amounts due, social security number, principal code, and diagnosis description); and Blue Cross and Blue Shield provider vouchers (includes account number, patient's name, contract of service, procedures, amount billed, amount paid, total billed amount, and net payments).

The files also include a level of care form (includes name of provider, name of attending physician(s), patient's name and date of birth, admission date, indication whether form used for submittal on admission, periodic report as requested, or change in level of care and effective date, a summary of skilled nursing care needed and frequency (weekly, daily, other), diagnosis, physical therapy, overall condition, date, signature of reporting nurse); and handwritten journal entries of totals for accounts receivable indicating the amount billed per patient per payment source (Medicare and Medicaid).

RETENTION

Retain 5 years.

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the care center's administrator and the requirements established by the State Division of Health Care Financing. The facility cost profile report (series 4469) requires the center "to keep for a period of 5 years such records as necessary to disclose fully the information contained herein."


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4469
TITLE: Facility cost profile report
DATES: i 1979-
ARRANGEMENT: Chronological by year
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: This annual financial report is required by the Utah Division of Health Care Financing. It is used as the basis for establishing a data base for rate calculations and is due two months after the end of the reporting period. The report includes balance sheets (containing current assets, description and amount, with handwritten notations), a statement of revenues and expenditures (description, current year, year to date, totals); and the facility cost profile report form.

The profile report form resembles an income tax form and consists of four individual schedules (Schedules A, C, D, and E). The report's cover sheet includes the name and address of the facility, type of facility, total number of licensed beds, type of ownership, and a certification attesting to the accuracy of the report signed by the center's administrator and report's preparer.__Schedule A includes the provider number, name of auditing firm and dates of last audit, questions concerning ownership, changes in rates, an attached balance sheet for the beginning and ending of period covered (expenses per general ledger, adjustments, facility cost profile reported expenses, audit adjustments and reclassifications), audited cost, patient days by type (private, Medicaid, Medicare, and Veterans Administration), total days reported, capacity (number of beds, days at capacity, total days), classification of facility and totals. Schedule C reports on Medicare revenue and includes period covered, facility cost profile reported revenue, totals, private revenue relating to period, other revenue not offset against cost, total revenue not offset against operating cost. Schedule C-2 includes the checklist of adjustments made to operating expenses and reported adjustments (income from patients, and miscellaneous income).

Schedule D reports on rental property, and Schedule E is a compilation of return on equity capital of proprietary procedures. The Pioneer Care Center does not use schedules D and E.

RETENTION

Retain 5 years.

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 5 years and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on the administrative needs expressed by the center's administrator and the requirements of the Utah Division of Health Care Financing stated on the report itself, whereby the administrator agrees "to keep for a period of 5 years such records as necessary to disclose fully the information contained herein."


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4471
TITLE: Medicare cost report
DATES: i 1977-
ARRANGEMENT: Chronological by year

DESCRIPTION: This is an audit report submitted annually by the center's auditor to Medicare. It is required of all Medicare providers on the "provider's accounting year" [42 Code of Federal Regulations (CFR) 413.2(b) (1989)]. This report includes the name and number of the provider, dates covered, administrator's signature and title, name and phone number of person to contact for additional information, financial data, whether report is audited or compiled, a series of questions on the provider's organization and operation, capital and related cost, interest expense, insurance, deferred compensation and pension, education activities, names of provider-based physicians, office costs of detailed accounting, amount of all Medicare funds, expenditures and revenues.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 5 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the center's administrator. The federal government does not specify a retention period for these records.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4238
TITLE: Monthly expenditure report
DATES: i 1986-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.20 cubic feet.

DESCRIPTION: This computer printout reports all expenditures of the Pioneer Care Center. It is used for budgeting and reference purposes. It includes department name and number, date, account number, description, purchase order number, warrant number, current expenditures, year-to-date expenditures, and totals. Attached to some of the some reports are copies of Request for Payment forms.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 3 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office. The county auditor maintains the record copy of these reports.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6654
TITLE: Pharmacy bills
DATES: i 1988-
ARRANGEMENT: Alphabetical by patient surname, thereunder chronological
ANNUAL ACCUMULATION: 1.50 cubic feet.

DESCRIPTION: These are files maintained by the nurses to verify the actual delivery of drugs to the care center. They are also used to create patient billings and are audited. The county auditor receives the yellow copy of the bill to make payment to the pharmacy. The files include the pink receipt from the pharmacy (name of patient, prescription number, amount charged and signature of person making receipt) attached to a care center form (patient's name, person making order, date, physician's name, order received by, drug and dosage, prescription number, amount requested and directions). After patient's discharge or death the file is removed and placed with the closed cases.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 6 years and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on both the legal requirements and administrative needs expressed by the center's administrator and the requirements established by the State Division of Health Care Financing. The bills are not only financially audited, but are also used to meet various contractual requirements. The Facility cost profile report (series 4469) requires the center "to keep for a period of 5 years such records as necessary to disclose fully the information contained herein."


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6663
TITLE: Insurance claims denied
DATES: i 1990-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.30 cubic feet.

DESCRIPTION: These files contain copies of denial notification letters from Medicare, Medicaid, and private insurance companies for financial reimbursement for various services provided by the care center. They are used to verify services provided.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office for 1 year after resolution of issue and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office. The record copies of these letters are maintained in the Patient financial records (series 5334).


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6668
TITLE: Staff committee minutes
DATES: i 1965-
ARRANGEMENT: Alphabetical by committee name, thereunder chronological
ANNUAL ACCUMULATION: 0.40 cubic feet.

DESCRIPTION: These files contain the official copies of all staff committees' minutes. They are used to document committees' actions and to verify their decisions. These committees include the Interdisciplinary Review Committee, Disaster Committee, Pharmacy Committee, Residence Committee, Patient Review Committee, Supervisors' Committee, and Infection Control Committee. The minutes include name of the committee, date, time, members present or absent, a summary of proceedings including any votes taken and decisions made.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 4 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the the center's administrator. The policy and procedure files (Series 6670) document the change in policies made by the staff committees and significant discussions are reported in the minutes of the Board of Trustees.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6670
TITLE: Policy and procedure files
DATES: i 1965-
ARRANGEMENT: Alphabetical by subject
ANNUAL ACCUMULATION: 0.40 cubic feet.

DESCRIPTION: These files document the creation, development, adoption, and revision of all care center policies and procedures. These policies encompass all care center activities including diet, housekeeping, maintenance, attendance, personnel, sick leave, administration, dress standards, drug testing, patient care, restraints, etc. The files include related correspondence, copies of policies, revisions, corrections, date approved and date revised.

RETENTION

DISPOSITION

Transfer to the State Archives with authority to weed.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years or until administrative need ends and then transfer to State Archives with authority to weed.

APPRAISAL

Administrative Historical

This disposition is based on the administrative needs expressed by the care center and the historical value of these records to document the development of policies for the care center.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6671
TITLE: Community Development Block Grant unsuccessful applications
DATES: i 1987-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: These files document unsuccessful attempts to receive applications for Community Development Block Grants (CDBG) for improvements to the care center. They are used for the application process and for writing future grants. These files include CDBG grant applications, the Bear River Association of Governments (BRAG) attachment applications, flyers for BRAG meetings and a summary of grants awarded.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 2 years after administrative need has ended and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the center's administrator.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6672
TITLE: Expense report
DATES: i 1990-
ARRANGEMENT: Numerical by budget line number
ANNUAL ACCUMULATION: 0.10 cubic feet.

DESCRIPTION: This is a report completed on specific expenses incurred per line item of the budget. It is used for the accounting of budget expenditures. The report includes date signed, information, items, prices, total expenses, balances, and handwritten tallies.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the care center.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6673
TITLE: Patient care review records
DATES: i 1984-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.30 cubic feet.

DESCRIPTION: These are convenience copies of review forms submitted to the Division of Health Care Financing. The original form is used to verify that patients admitted to medical institutions need to be there and are receiving proper care. The copy is used to verify that the form was submitted and is held until the center receives another copy of the original from Health Care Financing indicating acceptance of the patient's care. The acceptance copy is then filed in the patient's case file (series 06547). This information is required by 42 Code of Federal Regulations (CFR) 456 subparts C and E (1989).

These files include Preadmission/Continued Stay Inpatient Care Transmittal forms, Patient Care Transmittal, Continued Stay Review, and contact note sheets. Information includes an evaluation for the recipient's need for assistance, a plan of care, medical review, and certification by a physician that inpatient care is needed. Personal identifiers include age, alcohol or drug addiction, appearance, assets and debts, civil/criminal court involvement, current and past addresses, date of birth, employer, home ownership, income, marital status, medical information, membership in groups, name, name of kin, personality inventory, physical characteristics, physical disabilities, psychiatric information, religious preference, sex, signature, social security number, telephone number, name of provider, provider identification number, name of the attending physician, and any changes to the patient's condition or plan of care.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper copy: Retain in Office until acceptance received and then destroy.

APPRAISAL

Administrative

This disposition is based solely on the administrative needs expressed by the care center.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 7705
TITLE: Policy and procedure manuals
DATES: i 1965-
ARRANGEMENT: Alphabetical by subject

DESCRIPTION: These manuals document the approved policies and procedures for the day-to-day operation of the care center. They are used to provide guidelines for the administration, operation, rules and regulations for all personnel employed at the care center. These policies and procedures are regularly reviewed and updated to reflect new state and federal regulations and new concerns and methodology. The care center's administrator maintains the record copy of all policies.

RETENTION

DISPOSITION

Transfer to the State Archives with authority to weed.

FORMAT MANAGEMENT

Paper: Retain in Office for 5 years after superseded or until administrative need ends and then transfer to State Archives with authority to weed.

Paper copy: Retain in Office until superseded and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the care center and the reflects the Utah State Records Retention Schedule 1990 (Schedule 1, Item 23) and the Utah Municipal General Records Retention Schedule 1990 (Schedule 1, Item 12).


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6547
TITLE: Patient case files
DATES: i 1982-
ARRANGEMENT: Chronological, thereunder numerical by patient number

DESCRIPTION: These are the medical files for all Pioneer Care Center patients. They are used to document all treatment and care received by patients while admitted to the care center. These files include consent forms, substance records, physicians orders, medication records, nurses notes, and related correspondence. Four times a year files are weeded and less important forms are pulled and placed in storage files called "thinned files." At the patient's discharge or death these files are incorporated into the main files.

RETENTION

Retain 7 years

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 7 years after discharge or death of patient and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on both the records administrative needs expressed by center's administrator and the legal requirements. 42 Code of Federal Regulations (CFR) 483.75 (1990) provides that "clinical records must be retained for (i) The period of time required by state law; or (ii) Five years from the date of discharge when there is no requirement in State law." The state of Utah does not have a specific medical records statute. Utah Code Annotated (UCA) 78-14-4 (1990) provides that "No malpractice action brought against a health care provider may be brought unless it is commenced within two years after the plaintiff or patient discovers, or through the use of reasonable diligence should have discovered the injury, whichever first occurs, but not to exceed four years after the date of the alleged act." The care center has requested the records be maintained for seven years to meet all administrative needs and legal concerns.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6548
TITLE: Monthly medical charges
DATES: i 1989-
ARRANGEMENT: Chronological, thereunder alphabetical by charge type
ANNUAL ACCUMULATION: 0.50 cubic feet.

DESCRIPTION: These sheets record actual patient charges. Tags are attached to all medical supplies and are removed by nurses and attached to these sheets when they are used. These sheets are used to create charge slips (series 6549) which are then used to create patient billings. These sheets list all chargeable items including actual supplies used, and include nurse's initials, date, item cost, patient's name and date.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy.

APPRAISAL

Fiscal

This disposition is based on the fiscal needs expressed by the care center's office manager. These records have no value after they have been audited.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6549
TITLE: Charge slips
DATES: i 1987-
ARRANGEMENT: Chronological, thereunder alphabetical by charge type
ANNUAL ACCUMULATION: 0.50 cubic feet.

DESCRIPTION: These slips are created by the financial clerk from monthly medical charges (series 6548). They are used to create Medicare, Medicaid, and private billings. The slips include patient name, date, quantity, description, amount, total, and signature of financial clerk. Attached to these slips are the original statements from the pharmacy for prescriptions (name, address, date, payments, charges).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 3 years and then destroy.

APPRAISAL

Fiscal

This disposition is based on the fiscal needs expressed by the care center's office manager. These slips have no value after they have been audited.


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6551
TITLE: Pharmacy quarterly report
DATES: i 1990-
ARRANGEMENT: Chronological
ANNUAL ACCUMULATION: 0.20 cubic feet.

DESCRIPTION: These are three-part report forms completed on all drug irregularities. The pharmacist receives the original copy; the nurses supervisor and the center's administrator receive copies. They are used to follow up all drug irregularities. If forms cannot be completed fully, an incident report is completed and an investigation undertaken. The report includes the drug regimen review form (name of patient, medicine, date, times, and signature of registered nurse). This report form is divided into the following categories:__instances when regular medications are either not given or not properly charted; patients receiving diuretics with no potassium supplement (patient name, doctor's name, potassium level, date taken); patients whose pulse not recorded when taking dioxin (patient's name, date, doctor, person reporting); and patients taking multiple medication for same condition (patient medications, doctor, person reporting).

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 4 years or until resolution of any litigation and then destroy.

Paper copy: Retain in Office for 1 year and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on the administrative needs expressed by the care center and the statute of limitations provisions concerning malpractice. "No malpractice action against a health care provider may be brought unless it is commenced within two years after the plaintiff or patient discovers, or through the case of reasonable diligence should have discovered the injury, whichever first occurs, but not to exceed four years after the date of the alleged act, omission, neglect or occurrence" [Utah Code Annoted (UCA) 78-14-4.4 (1990)].


AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6552
TITLE: Daily observation notebooks
DATES: i 1990-
ARRANGEMENT: Chronological, thereunder alphabetical by location
ANNUAL ACCUMULATION: 1.00 cubic foot.

DESCRIPTION: These are notebooks maintained by the nurses which contain daily handwritten notations on all patients. They are used to create survey reports. They include date, hall location, room number, patient's first name, and nurses' observations.

RETENTION

DISPOSITION

Destroy.

FORMAT MANAGEMENT

Paper: Retain in Office for 2 years after completion of survey reports and then destroy.

APPRAISAL

Administrative

This disposition is based on the needs expressed by the nursing supervisor.