Handling of Resident Records
The primary purpose of the resident records review at SV is to maintain the quality and integrity of the resident’s chart. This is done through qualityassurance audits. These audits are done per HIPPA Laws, The Joint Commission standards, California statute laws, and SV internal policies. The secondary purpose is to fulfill resident record requests made by external organizations. To complete the request in a timely manner and abide by all laws and regulations regarding authorizations to release information. It is the policy of SV to establish procedures for the practice of Resident records retention and distribution.
- External Requests – Always follow proper protocol when faxing or mailing a resident record. The protocol is as follows:
- Resident records may be requested by mail, fax, email, phone or in person.
- All requesters must have Authorization for Release of Information before any records will be released.
- Resident records personnel must always verify the resident’s signature, social security, and/or D.O.B by either a driver license or some other type of identification.
- All records must be pulled, analyzed, and sent within thirty (30) days of receiving the request.
- If a release/request of information was received and no record was found on the resident, then the release will be returned to the requestor with notice of request for information form.
- The following lists are the only documents that are to be sent out:
- History and physical, including TB test results
- Integrated Summary
- Lab results
- Discharge Summary
G. All charts must be thoroughly audited before being sent out. Please use
Discretion when sending out personal information to anyone.
H. All requests must be filed and a record of them should be kept on file. This
Is to ensure that all requests made were fulfilled and in a timely manner.
- If a requester for some reason is requesting information that we do not provide in SV standard procedures, the release will need approval from the Administrator. Once approval is received, the records can be released.
2. Internal Audits – Audits are completed as follows:
- Going through the resident document checklist, making sure that all documents are in the chart as they are supposed to be. Anything missing, incomplete or incorrect needs to be noted on this document. The auditor needs to date this document.
- All missing documents, blank lines, missing signatures, incomplete documents, incorrect documentation, and any other errors found in the record need to be documented. These deficiencies will be e-mailed to the appropriate staff members and their supervisor.
- All documents are signed and dated with all the proper and/or qualified professionals’ signature.
- All records have a picture of the resident.
- All sections of the record are completed in a timely manner. Discharges completed no more than fourteen (14) days after the resident discharges from the facility. Clinical notes should be documented on a daily basis. Each department is aware of their time lines.
- TB’s need to be read on the specified time and recorded completely.
- Treatment plans need to be completed on all residents.
- All documents need to be completely filled in, leaving nothing blank on any of the documents in the chart.
- On the third Tuesday of each month, a report will be provided to the performance improvement committee. It will be a summary of charts audited during the month and all electronic reports provided by the electronic resident record.
- All records being sent to any external source needs to be thoroughly audited before leaving the facility.
Resident Records Deficiency
It is the policy of SV that all resident record deficiencies shall be completed within 14 days of the resident’s discharge.
- All resident records shall be completed within 30 days of the resident’s discharge.
- All resident record deficiencies shall be completed within fourteen (14) days of the resident’s discharge.
- The Administrator will report all deficiencies to the CEO as necessary.
- The CEO will take appropriate actions as deemed necessary.
Correction of Resident Record Errors
It is the policy of SV that resident record documentation errors may be corrected only in a manner that preserves their integrity. The electronic resident record can be documented by adding a Note Update or Assessment Update to the form. In this update, the error will be noted, and the correct information will be documented.
The correction needs to be documented, including which entry the correction is replacing, and dated. In questionable situations, have the corrected notation witnessed by a colleague. Nothing may be removed or deleted from a resident record, and no irrelevant or facetious notations may be made in them.
Records Reviewed by Court Order
It is the policy of SV to review all resident records requested by a court order prior to release.
- A copy of the resident record can be released in the case of a Court Order. The resident record will be taken to the Court under the jurisdiction of the Administrator.
- Preparing a record for release to the Court:
- The record will be examined subject to a Court Order to make certain that it is complete, that signatures and initials are legible, that each page identifies the resident.
- The resident record will be analyzed by an employee to determine whether the case forms the basis for a possible negligent action against SV.
- Only pertinent information requested by the court order shall be provided.
- Records to present shall be printed from the electronic system.
It is the policy of SV to assure that the information in the resident’s healthcare records and any information pertaining to the identity of a resident, the resident’s diagnosis, pronosis, treatment and condition are treated as confidential and disclosed only to authorized persons as stipulated by 42 Code of Federal Regulations, part 2 governing the alcohol and drug abuse treatment records. SV residents records are also protected under standards for privacy of individuality, identifiable health information 45 Code of Federal Regulation part 160-164 (also referred to as HIPPA). When there is a conflict between regulations, the most restrictive will apply.
A “Consent and authorization for release of information” form must be signed by the resident indicating to whom SV is authorized to release information. The resident confedetiality will be maintained, and information will not be divulged without prior approval. The residents may revoke consent at any time.
Prior to release, the administrator or his/her designee must approve all authorized releases madeby SV. When answering the telephone, SV staff will never confirm or deny a resident is part of the program without express written consent of the resident. In addition the program ensures confidentiality of closed files and their distruction, as outlined in the resident files privacy.
Federal and state confidentiality regulations authorize disclosure of information regarding the identity, diagnosis, prognosis or treatment of alcohol and/or other drug program resident/residents under specific guidelines. SV shall adhere to the regulations stipulated in the code of federal regulations (Titles 42, Sections 2.1 through 2.67- 1), the state of California Welfare and Institutions Code (section 5326 through 5330) and other provisions.
Any information, recorded or not, related to a resident of SV, is to be afforded full confidentiality as outlined in the above regulations. Exceptions to confidentiality are as follows:
- If information about suspected child/dependent adult/elderly abuse or neglect is reported.
- If resident/residents threaten to harm themselves or others.
- If the Court orders that resident information be released.
- If the resident provides written permission to release information.
- Disclosure is made to medical personnel in a medical emergency or to quailified personnel for research, audit or program evaluation.
Violation of the Federal and State Laws and Regulations by a program is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs. Federal regulations allow information sharing among programs with Qualified Service Organization Agreements (QSOA’s), as follows:
- All staff and volunteers shall sign an Oath of Confidentiality before they begin working with SV.
- The Confidentiality Policy and the exceptions to confidentiality must be explained fully to resident/residents at the time of intake.
- Telephone Answering: Program staff properly trained to do so will answer the telephones. All staff shall be trained to not acknowledge whether an individual is a resident/resident of the program. All inquiries regarding the individuals that are, or have been, or might be a potential resident/ resident in the program should be treated with complete confidentiality, the caller shall be respectfully informed that this information cannot be acknowledged either way and that if they would like to speak to another staff person, the call will be transferred.
- Resident/residents file access: Resident/resident’s files will be maintained in a locked office and file cabinet, which can also be locked. Information maintained in a computer is protected by password.
- Release of information: Information regarding a resident/resident may be shared to the extent that a release of information, signed by the resident/ resident permits.
- No employee shall use or disclose privileged or confidential information gained in the course of work or by reason of his/her official position or activities.
Staff who fail to abide by SV’s program’s Confidentiality Policy are subject to termination of employment. SV has a lawful duty to safeguard confidential information concerning clients, alumni, staff members and agency business. Unauthorized accessing and/or disclosure of confidential information by agency employees are prohibited and may result in disciplinary sanctions.
SV acknowledges that prospective, current and former clients and staff members have the right to privacy and protection against release of personal information to sources that have no legitimate need for such data. SV clients and staff members alike shall receive maximum protection against invasion of their privacy.
Restrictions and Violations
There are state laws, federal guidelines, and agency policies that govern the release of confidential information:
- Staff members may not obtain access to or provide confidential information unless their positions within the agency authorize them to do so, and the appropriate release authorization has been obtained.
- When in question, staff members who receive requests for confidential information should seek direction from a supervisor before responding.
- Staff members who violate the agency’s Confidential Information policy may be disciplined up to and including dismissal.
Staff members are responsible for knowing the confidentiality laws, policies and guidelines that pertain to their location. Staff members sign a client confidentiality acknowledgement upon hire. In addition, supervisors are responsible for informing staff members about restrictions on confidential information. All employees must strictly comply with this policy. When in doubt, they should assume information is confidential and not disclose it until if/when they are authorized to do so.
SV staff members shall maintain client confidentiality in all communications in accordance with Federal Guidelines (42 CFR Part 2) and HIPAA Regulations (45 CFR). In addition to a Confidential Information Release Authorization, the following disclosure will accompany all electronic transmissions of confidential client information in compliance with Federal Guidelines and HIPAA Regulations on confidentiality:
“Protected Health Information (PHI) is personal and sensitive information
related to a person’s health care. It is being faxed to you after appropriate authorization from the resident or under circumstances that do not require
resident authorization. You, the recipient, are obligated to maintain it in a
safe, secure and confidential manner. Re-disclosure without additional
resident consent or as permitted by law is prohibited.
Unauthorized disclosure or failure to maintain confidentiality could subject
you to penalties described in federal and state laws. This transmission is
intended only for those to which it is addressed and may contain information
that is privileged, confidential, or protected by law. All others are hereby
notified that receipt of this message does not waive any applicable privilege
or exemption from disclosure and that any dissemination, distribution, or
copying of this communication is prohibited. If you have received this communication in error, please notify us immediately and shred this documentation.”
Client Notification of Confidentiality Requirements
At the time of the client’s initial assessment, staff shall inform the client of California and federal laws and regulations that protect the confidentiality of their treatment episode along with records thereof.
Upon intake the client shall be given a written summary of the laws and regulations governing confidentiality. The client will read, acknowledge and sign the summary. A copy of this acknowledgement is to be kept in the client record.
Release of Confidential Employee Information
The agency limits the authorized release of reference information on current/former employees to confirmation of dates of employment, position(s) held and salary verification. Requests for employment verification must be received via fax, email or postal mail and include an authorized signature for release of the information.
Any further information provided by residents is construed to be a personal reference for which the agency is not responsible.
SV does not normally conduct research as a matter of practice; however, we reserve the right to initiate this process. If SV does conduct research using residents as subjects, we shall comply with all standards of the California Research Advisory Panel and the federal regulations for protection of human subjects (Title 45, Code of Federal Regulations, 46).
All individuals who apply for services, regardless of sex, race, age, color, creed, financial status, or national origin, are assured that their lawful rights as Clients shall be guaranteed and protected. While being served, you the Client are assured and guaranteed the following rights:
1. To be treated with respect and dignity.
2. To receive timely treatment by qualified professionals.
- Every effort will be made to use the least restrictive, most appropriate treatment available, based on Client needs.
- Each Client shall be afforded the opportunity to participate in activities designed to enhance self-image.
- An individualized treatment plan shall be developed for each Client in accordance with the provisions established for each program component.
3. To receive quality treatment that is best suited to his/her needs and shall include appropriate services, whether they be medical, vocational, social, educational, and/or rehabilitative services.
4. To express by signature an informed consent of the right to release information for communication purposes with other agencies.
5. To receive communication and correspondence from individuals.
6. To privacy for interview/counseling sessions.
7. To practice your religious practices.
8. To be provided humane care and protection from harm.
9. To contract and consult with legal counsel and private practitioners of your choice at your expense.
10. To exercise your constitutional, statutory, and civil rights.
11. To be free of physical restraint or seclusion.
12. To be informed of the nature of treatment or rehabilitation, the known effects of receiving the treatment or rehabilitation, and alternative treatment or rehabilitation programs.
13. To be provided information on an ongoing basis regarding your treatment or rehabilitation.
14. To be provided services in accordance with standards of practice, appropriate to your needs, and designed to afford you a reasonable opportunity to improve your condition.
15. To confidentiality of the Client being in treatment and of the Client’s records. The Federal Rules restricts any use of information to criminally investigate or prosecute any alcohol or drug abuse Client. Federal regulations state any person who violates any provision of the law shall be fined not more the $500.00 in the case of the first offense and not more than $5,000.00 in the case of each subsequent offense, except where noted in the Federal Law of Confidentiality, 42 CFR, Part 2, Section 2.22, which includes the following:
- The limited circumstances of release of Client information includes, crimes on program premises or against program personnel, medical emergencies, mandated reports of child abuse or neglect, elderly abuse, threats to harm self or others, research, audit and evaluations, or court orders.
16. To receive full information regarding the treatment process.
17. To refuse treatment.
18. To all other constitutional and legal rights, including the right to personal clothing and effects.
19. To be informed of the Client grievance procedure upon request.
Confidentiality of Alcohol and Drug Abuse Patient Records/Limits to Confidentiality:
The confidentiality of alcohol and drug abuse Client records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that Client attends the program or disclose any information identifying a Client as an alcohol or drug abuser unless:
- The Client consents in writing
- The disclosure is allowed by a court order; or
- The disclosure is made to medical personnel
- The disclosure to a qualified person for research, audit or program evaluation; or
- The disclosure is made to protect self or others or a crime has been committed; or
- The disclosure in the event of threats of harm to self or others (Duty To Warn).
Violation of the Federal law and regulations by a program is a crime. Suspected violation may be reported appropriate authorities in accordance with Federal regulations.
Federal law and regulations do not protect any information about a crime committed by Client either at the program or against any person who works for the program or about any threat to commit such a crime.
Federal laws and regulations do not protect any information about elderly abuse, suspected child abuse or neglect, threats to harm to self or others from being protected. These may be released under State law to appropriate State or local authorities beyond Federal CFR42-Regulations.
(See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR Part 2 for Federal regulations,)
1. Any person(s) who believes that their rights have been violated or has a compliant or grievance may file a complaint pursuant to the procedures set forth below, on their behalf or on the behalf of another person. All persons are encouraged to file a grievance. By filing a complaint the individual will not subject themselves to any form of adverse action, reprimand, retaliation, or otherwise negative treatment by SV Recovery. Client shall have immediate access to the grievance form; a posting of the grievance procedure will be in the group room with the levels of appeals, and in the Patient handbook.
2. The processing procedures for grievances and complaints are as follows:
- The Client is encouraged to discuss any problems with their therapist. The Client and therapist will try to find a resolution. The therapist will correspond with the Clinical Director on the grievance and/or compliant and any resolution.
- All grievances shall first be filed with the Clinical Director by completing a “Client Grievance” form. The Human Resources Director and/or Designee shall give the Client a receipt of the filed grievance and log the grievance. The Director will conduct an internal investigation and render an initial determination and resolution within 2 days of receipt of the complaint in writing.
- If the complainant is not satisfied or if the complaint is not resolved with the results achieved in Step 2, the complainant may file an appeal and/or the grievance shall be forwarded to the Executive Director and this meeting shall be held within five working days of the date it is requested.
- The Client shall be presented a resolution and response to their grievance in writing.
- In the event that the Client does not feel a resolution has been reached they may contact the state regulatory department and the applicable client advocacy institution.
3. The Clinical Director and the Director shall take steps to ensure an appropriate investigation of each complaint to determine its validity. These rules contemplate informal, but thorough, investigations affording all interested persons and their representatives, if any, an opportunity to submit evidence relevant to the complaint.
4. Any allegations of physical or sexual abuse by a therapist shall immediately be brought to the attention of the Clinical Director and the police shall be notified. The Client will be afforded the opportunity to contact the Police, state Abuse Hotline, state department of family services and the state disability rights department where applicable. The telephone numbers of the hotlines are posted on the Client Bulletin Board.
ALCOHOL RECOVERY AND DRUG TREATMENT FACILITIES C-9
In accordance with Title 9, Chapter 4, Section 10569, of the California Code of Regulations, each person receiving services from a residential alcoholism or drug abuse recovery or treatment facility shall have rights which include, but are not limited to, the following:
1. The right to confidentiality as provided for in Title 42, Sections 2.1 through 2.67-1, Code of Federal Regulations. A copy is available upon your request.
2. No client will be discriminated against on the basis of race, religion, age, sex, disability, handicaps, national ancestry, ethnic group identification, color, or sexual orientation. No client will be denied the opportunity to participate in the recovery program on the basis of any form of discrimination.
3. To be treated with dignity and respect in personal relationships with staff, volunteers, Board Members and other persons.
4. To be accorded safe, healthful, and comfortable accommodations to meet his or her needs.
5. To be free from verbal, intellectual, emotional and/or physical abuse and inappropriate sexual behavior.
6. To be informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the Department of Health Care Services. (See below)
7. To be informed by the program of the procedures to file a grievance or appeal discharge.
8. To be free to attend religious services or activities of his or her choice and to have visits from a spiritual advisor provided that these services or activities do not conflict with facility program requirements. Participation in religious services will be voluntary only.
9. To be accorded access to his or her file.
In accordance with Title 9, Chapter 4, Section 10543(a), of the California Code of Regulations, any individual may request an inspection of an alcoholism or drug abuse recovery or treatment facility. Complaints should be directed to:
Lilit Yegiazaryan, MD
SV Recovery, Inc.
10420 Penrose Street
Sun Valley, CA 91352
To report details of your complaint to the State:
Department of Health Care Services
Licensing and Certification Branch, MS 2600
P.O. Box 997413, MS 2600
Sacramento, CA 95899-7413
Attention: Complaint Coordinator
Tel: 916-322-2911 or 877-685-8333
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
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a copy of your health and claims records
• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records
• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communication
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will consider all reasonable requests and must say “yes” if you tell us you would be in danger if we do not.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it would affect your care.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on the back page.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in payment for your care• Share information in a disaster relief situation
If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways.
Help manage the health care treatment you receive
• We can use your health information and share it with professionals who are treating you.
Run our organization
• We can use and disclose your information to run our organization and contact you when necessary.
• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Pay for your health services
• We can use and disclose your health information as we pay for your health services.
Administer your plan
• We may disclose your health information to your health plan sponsor for plan administration.
Our Uses and Disclosures
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
Help with public health and safety issues
• We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
• We can use or share your information for health research.
Comply with the law
• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director
• We can share health information about you with organ procurement organizations.
• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers compensation, law enforcement, and other government requests
• We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
• We can share health information about you in response to a court or administrative order, or in response to a subpoena.
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our website, and we will mail a copy to you.