ST. THERESE HOMES, INC.
NEW
POLICY # AD-13
PAGE 1 OF 16
DATE: April 2003
SUBJECT: Health Insurance Portability and Accountability Act (HIPAA)
DISTRIBUTION: ALL DEPARTMENTS
SUPERSEDES: NEW POLICY
POLICY: To provide compliance for Federal protection for the privacy of health information but not inhibit the resident's access to or the quality of health care delivery.
PURPOSE: Creates National standards to protect individual’s medical records and other personal health information. The plan also describes the ways St. Therese may use and disclose information, and the rights of the resident and certain obligations of the faculty to use and disclose information.
RESPONSIBILITY: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
· If you have any questions about this notice, please contact the QI Manager for Resident Issues
HOW WE MAY USE AND DISCLOSE
MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. See authorization form and consent form (attachments 1 & 6).
v
For Treatment: We may use medical information about you
to provide you with medical treatment or services. We may disclose medical information about you
to doctors, nurses, technicians, medical students, or other facility personnel
who are involved in taking care of you at St. Therese. For example, if our nurses are caring for
your broken leg, they may need to know if you have diabetes because diabetes
may slow the healing process. In
addition, the doctor may need to tell the dietitian if you have diabetes so
that we can arrange for appropriate meals.
Different departments of the facility also may share medical information
about residents in order to coordinate your different needs, such as physical
and occupational therapy or social services.
We also may disclose medical information about you to people outside the
facility who may be involved in your medical care after you leave St. Therese,
such as family members, or others we use to provide services for your care.
v
For Payment:
We may use and disclose medical information about you so that the
treatment and services you receive at the facility may be billed and payment
may be collected from you, an insurance company or a third party. For example, we may need to give your health
plan information about care you have received at St. Therese so your health
plan will pay us or reimburse you. We
may also tell your health plan about a treatment you are going to receive to
obtain prior approval or to determine whether your plan will cover the
treatment.
v
For Health Care Operations: We may use and disclose medical
information about you for facility operations.
These uses and disclosures are necessary to run the facility and make
sure that all of our residents receive quality care. For example, we may use medical information
to review our treatment and services and to evaluate the performance of our
staff in caring for you. We may also
combine medical information about many facility residents to decide what additional
services the facility should offer, what services are not needed, and whether
certain new treatments are effective. We
may also disclose information to doctors, nurses, technicians, medical
students, and other facility personnel for reviewing and learning
purposes. We may also combine the
medical information we have with information from other facilities to compare
how we are doing and see where we can make improvements in the care and
services we offer. We may remove
information that identifies you from this set of medical information so others
may use it to study health care and health care delivery without learning who
the specific residents are.
v
Appointment Reminders: We may use and disclose medical information
to contact you as a reminder that you have an appointment for treatment or
medical care at St. Therese.
v
Treatment Alternatives: We may use and disclose medical
information to educate you or recommend possible treatment options or
alternatives that may be of interest to you.
v
Health-Related Benefits and Services: We may use and disclose medical
information to tell you about health-related benefits or services that may be
of interest to you.
v
Fundraising Activities: We may use medical information about you
to contact you in an effort to raise money for the facility and its
operations. We may disclose medical
information to a foundation related to the facility so that they may contact
you in raising money for their facility.
We only would release contact information such as your name, address and
phone number and the dates you have received treatment or services at St.
Therese. If you do not want St. Therese
to contact you for fundraising efforts, you must notify Dan Jasper, Fund
Development, in writing.
v
Facility Directory: Unless you object, we may include certain
limited information about you in the facility directory while you are a
resident at St. Therese. This
information may include your name, location in the facility, and your religious
affiliation. The directory information,
except for your religious affiliation, may also be released to people who ask
for you by name. Your religious
affiliation may be given to a member of the clergy even if they do not ask for
you by name. This assists family,
friends, and clergy in visiting you and knowing your general condition.
v
Individuals Involved in Your Care or Payment
for Your Care: We may release
medical information about you to a friend or family member who is involved in
your medical care. We may also give
information to someone who helps pay for your care. We may also tell your family or friends your
condition and that you are a resident at St. Therese. In addition, we may disclose medical
information about you to an entity assisting in a disaster relief effort so
that your family can be notified about your condition, status and location.
v
Research:
Under certain circumstances, we may use and disclose medical
information about you for research purposes.
For example, a research project may involve comparing the health and
recovery of all residents who received a certain medication to those that
received another, for the same condition.
All research projects are subject to a special approval process. This process evaluates a proposed project and
its use of medical information, trying to balance the research needs with the
resident’s needs for privacy of their medical information. Before we use or disclose medical information
for research, the project will have been approved through this research
approval process. However, we may
disclose medical information about you to people preparing to conduct a
research project. This may include
assisting researchers to find residents with specific medical needs, so long as
the medical information they review does not leave the facility. We will almost always ask for your specific
permission it the researcher will have access to your name, address or other
information that reveals who you are, or will be involved in your care at the
facility.
v
As Required By Law: We will disclose medical information
about you when required to do so by federal, state or local law.
v
To Avert a Serious Threat to Health or
Safety: We may use and disclose
medical information about you when necessary to prevent a serious threat to
your health and another person. Any
disclosure, however, would only be to someone able to help prevent the threat.
v
Organ and Tissue Donation: If you are an organ donor, we may release
medical information to organizations that handle organ procurement or organ,
eye or tissue transplantation or to an organ donations bank, as necessary to
facilitate donation and transplantation.
v
Military and Veterans: If you are a member of the armed forces,
we may release medical information about you as required by military command
authorities. We may also release medical
information about foreign military personnel to the appropriate foreign
military authority.
v
Workers’ Compensation: We may release medical information about
you for workers’ compensation or similar programs. These programs provide benefits for
work-related injuries or illness.
v
Public Health Risks: We may disclose medical information about
you for public health activities. These
activities generally include the following:
o
To prevent or control disease, injury or
disability;
o
To report deaths;
o To report vulnerable adult issues or neglect;
o To report reactions to medications or problems with products;
o To notify people of recalls of products they may be using;
o To notify a person who may have been exposed to a disease or at risk for contracting or spreading a disease or condition;
o To notify the appropriate government authority if we believe a resident has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
v Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include: audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
v
Lawsuits and Disputes: If you are involved in a lawsuit or a
dispute, we may disclose medical information about you in response to a court
or administrative order. We may also
disclose medical information about you in response to a subpoena, discovery
request, or other lawful process by someone else involved in the dispute. This is put into effect only if efforts have
been made to tell you about the request or to obtain an order protecting the
information requested.
v
Law Enforcement: We may release medical information if
asked to do so by a law enforcement official:
o In response to a court order, subpoena, warrant, summons or similar process;
o To identify or locate a suspect, fugitive, material witness, or missing person;
o About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
o About a death we believe may be the result of criminal conduct;
o About criminal conduct at the facility; and
o In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
v Coroners, Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine that cause of death. We may also release medical information about residents of St. Therese to funeral directors as necessary to carry out their duties.
v National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
v Protective Services for the President and Others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
v Inmates: If you are an inmate of a correctional institution or under custody of a law enforcement official, we may release medical information about you to the institution or official. This release would be necessary
o For the institution to provide you with health care;
o To protect your health and safety or the health and safety of others; or
o For the safety and security of the correctional institution.
INFORMATION ABOUT YOU
v
Right to Inspect and Copy: You have the right to inspect and copy
medical information that may be used to make decisions about your care. Usually, this includes medical and billing
records, but does not include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Health Information where a form is available. (See attachment 2). If you request a copy of the information to review your current medical care, we will provide that without cost. For other requests, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We also recommend that a medical professional be available to answer any questions.
We may deny your request to inspect and copy in certain, very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the facility will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
You have the right to inspect the Authorization and Consent to Use and Disclose Information form that is used upon admission to St. Therese. (See attachment 1).
v Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for St. Therese.
To request an amendment, your request must be made in writing and submitted to Quality Improvement where a form is available. (See attachment 3). In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
o Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
o Is not part of the medical information kept by or for the facility;
o Is not part of the information which you would be permitted to inspect and copy; or
o Is accurate and complete.
v Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. Not all disclosures are subject to this accounting requirement.
To request this list or accounting of disclosures, you must submit your request in writing to the QI Manager where a form is available. Your request must state a time period, which may not be longer than seven years and may not include dates before admission. Your request should indicate in what form you want the list i.e.) on paper or electronically. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. (See attachment 4).
v Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or a friend. For example, you could ask that we not use or disclose information about a surgery you had.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the QI Manager where a form is available. In your request you must tell us
o What information you want to limit;
o Whether you want to limit our use, disclosure or both; and
o To whom you want the limits to apply, i.e. your spouse.
(See attachment 5)
v Right
to Request Confidential Communications: You
have the right to request that we communicate with you about medical matters in
a certain way or at a certain location.
For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to Quality Improvement. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
v Right
to a Paper Copy of This Notice: You
have the right to a paper copy of this notice.
You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this
notice electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice contact Social Service.
CHANGES TO THIS NOTICE
v We
reserve the right to change this notice.
We reserve the right to make the revised or changed notice effective for
medical information we already have about you as well as any information we
receive in the future. We will post a
copy of the current notice in the facility.
The notice will contain the effective date in the top right-hand corner
of the first page
COMPLAINTS
v
If you believe your privacy rights have been
violated, you may file a complaint with the facility or with the Secretary of
the Department of Health and Human Services.
To file a complaint with
You will not be
penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
v Other
uses and disclosures of medical information not covered by this notice or the
laws that apply to us will be made only with your written permission. If you provide us permission to use or
disclose medical information about you, you may revoke that permission, in
writing, at any time. If you revoke your
permission, we will no longer use of disclose medical information about you for
the reasons covered by your written authorization. You understand that we are unable to take
back any disclosures we have already made with your permission, and that we are
required to retain our records of the care that we provided to you.