Screening records — retention, integrity and producing evidence for a surveyor, auditor or investigator
Template version 2026-10-06 — adopted by: ____________________  effective: __________  owner: Compliance Officer (owner); Health Information Management / Records (custodian); IT (systems)

Template. Written against the public text of the standard cited; the organization adopts, edits and owns it as its protocol. Every threshold, identity, hold or disclosure decision belongs to the organization. We report the findings against the protocol — counts, dates, states — nothing more. Not legal advice, not a compliance determination, not a consumer report.

STANDARDS SERVED
- OIG General Compliance Program Guidance — documentation of the compliance program's operation — https://oig.hhs.gov/compliance/general-compliance-program-guidance/
- False Claims Act statute of limitations — up to 10 years (31 U.S.C. 3731(b)); informs retention — https://www.law.cornell.edu/uscode/text/31/3731
- 2 CFR 200.334 — record retention for federal awards (3 years from final report, longer if audit or litigation) — https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/section-200.334
- Federal Rules of Evidence 902(13)/(14) — certified records of a process; hash-verified copies — https://www.law.cornell.edu/rules/fre/rule_902

SCOPE
All screening receipts, roster files, review logs, decisions and measures produced under HOSP-01 through HOSP-07.

FREQUENCY
Retention continuous; integrity check and producibility drill quarterly.

PROCEDURE
1. Set the retention period here, with counsel: ___ years (the FCA limitations period of up to 10 years and 2 CFR 200.334 are the usual anchors). Records of what a file printed are retained and never edited; a wrong record is marked superseded with a note, not deleted.
2. Each receipt carries a SHA-256; keep the hash with the record. Where the issuer anchors daily hashes to a public timestamp, keep the proof reference — it shows the record existed by that date without relying on the issuer.
3. Quarterly integrity check: sample ___ receipts across months; recompute or verify each hash against the issuer's public verify route; record pass/fail. Any failure is an incident.
4. Quarterly producibility drill: a person not on the compliance team picks a name and a month; time how long it takes to produce the dated record, the review log and the decision. Record the minutes.
5. On a survey, audit or investigation request: produce the records as kept, with the hash and proof reference; if a declaration of the record-keeping process is needed, use the issuer's system declaration (FRE 902(13)) plus your own custodian statement.
6. Never alter a record to fit a request; if a record is wrong, the correction is a new record that cites the old one.

MEASURES (findings reported monthly; the threshold for each is your protocol's)
- Hash verification pass rate: sampled receipts whose hash verifies ÷ sampled. Data: verify route results. Threshold: your protocol: ________
- Producibility: minutes to produce a sampled month's record, log and decision. Data: quarterly drill. Threshold: your protocol: ________
- Retention compliance: records inside the retention period still retrievable ÷ sampled. Data: drill. Threshold: your protocol: ________
- Unedited records: records found altered after creation. Data: integrity check. Threshold: your protocol: ________

RECORDS
- Retention schedule and its notations — kept by Compliance Officer — retention indefinite
- Integrity check and drill results — kept by Compliance — retention per schedule
- Request-response log (who asked, what was produced, when) — kept by Compliance — retention per schedule

WHAT THIS PROCEDURE DOES NOT DECIDE
Privilege, scope of production, and the legal retention period — counsel's. The template describes how to keep records so they are producible and provably unaltered.

CHANGE LOG (add a line for every change; keep superseded versions)
- 2026-10-06: First issue.
- ________: adopted/edited by ____________________

Source template: https://alphacovenantholdings.com/api/public-record/sop-templates/hosp-08-records-and-audit-response/html · Duty Sheets: https://alphacovenantholdings.com/api/public-record/duty-sheets · Our own procedures: https://alphacovenantholdings.com/api/trust/sops