OAC 173-39-02.12 / 173-39-02.02 · Record Retention Compliance

Record Retention Attestation

Dulla Care Home Healthcare

Person(s) Responsible for Maintaining Personnel Files

Purpose

This attestation is signed and dated by the person(s) in charge of maintaining personnel files at Dulla Care Home Healthcare. By signing, the individual certifies that they have reviewed and understand all record retention requirements under Chapter 173-39 of the Ohio Administrative Code and all applicable Ohio regulations. This signed attestation is retained in the administrative file and renewed annually.

Person Responsible for Personnel Files

Full Name

Title / Position

Department

Phone

Date

Acknowledgment of Record Retention Requirements

I acknowledge that I have reviewed and understand the following record retention requirements:

Personnel files must be retained for a minimum of 6 years following termination of employment, per Ohio Medicaid requirements.Personnel files include: employment application, I-9, W-4, background check results, training records, certifications, performance evaluations, disciplinary records, and signed acknowledgments.Consumer service records must be retained for a minimum of 6 years per OAC 173-39-02.11, including service verification documentation, care plans, and incident reports.All background check results (BCI, FBI, and database screenings) must be retained in the personnel file for the duration of employment and 6 years thereafter.All staff training records, including orientation, annual training, and competency evaluations, must be retained in personnel files and available for review.Current certificates of insurance (general liability, workers' compensation, and bonding) must be retained and renewed annually, with evidence available for review at all times.This attestation must be renewed annually and retained in the administrative file for review during compliance reviews and audits.All records must be made available for review by ODA, ODM, ODA designees, MCO auditors, or CMS upon request, in accordance with Chapter 173-39 of the Ohio Administrative Code.

⚠ Please review and acknowledge all items above.

Attestation

I, [Full Name], in my capacity as [Title]at Dulla Care Home Healthcare, hereby attest that I have reviewed and understand all record retention requirements under Chapter 173-39 of the Ohio Administrative Code and all applicable Ohio regulations. I understand my responsibility to maintain, retain, and make available all personnel files, consumer records, and supporting documentation in accordance with these requirements for the duration specified by law. I further understand that failure to maintain proper records may result in disciplinary action under OAC 173-39-05. This attestation is renewed annually and retained in the administrative file.

Signature

Date

2026-10-28

Witnessed By (Administrator)

Administrator Name

Date

Administrator Signature

Title

Dulla Care Home Healthcare · Record Retention Attestation · OAC 173-39-02.12 / 173-39-02.02 · Renewed Annually · Retained in Administrative File · Confidential