To ensure that a Notice of Privacy Practices is disseminated to and acknowledged by each resident or their responsible party upon admission to the facility.
It is the policy of the facility to disseminate a written notice to all residents that addresses its policies and procedures with respect to the use and disclosure of protected health information and with respect to the facility’s legal duties with respect to such information (a "Notice of Privacy Practices").
The Notices of Privacy Practices shall include all elements and statements that are required by law. In summary, the Notice shall inform the residents about the potential uses and disclosures of the health information, as well as their rights with respect to that information, including: (1) a description of each of the purposes for which the facility is permitted to disclose their health information, including, for example, treatment, payment, and health care operations; and (2) a description of when written authorization is required before the facility may disclose the individual’s health information in other instances.
Protected Health Information (PHI)
Information that is a subset of health information, including demographic information, and
- Is created or received by a health care provider, health plan, employer, or health care clearinghouse, and
- Relates to the past, present, or future physical or mental health or condition of an individual the provision of health care to an individual; and
- That identifies the individual; or
- There is a reasonable basis to believe the information can be used to identify the individual.
The release, transfer, provision of access to, or divulging in any other manner of health information outside of the facility.
The provision, coordination, or management of health care and related services by the facility, including the coordination or management of health care by the facility with a third party; consultation with other health care providers relating to a resident; or the referral of a resident for health care between the facility and another health care provider.
The activities undertaken by a health care provider or payer to obtain reimbursement for the provision of health care.
Health Care Operations
Any of the following activities of the Facility:
- Conducting quality assessment and improvement activities, provided that the obtaining of generalizable knowledge is not he primary purpose of any studies resulting from such activities; protocol development, case management and care coordination, contacting of health care providers and patients with information about treatment alternatives; and related functions that do not include treatment;
- Reviewing the competence or qualifications of health care professionals, evaluating employee and Facility performance, conducting training programs under supervision to practice or improve skills, training of non-health care professionals, accreditation, certification, licensing, or credentialing activities;
- Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs;
- Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating Facility;
Business management and general administrative activities of Facility, including, but not limited to: Customer service;
Resolution of internal grievances;
Due diligence in connection with the sale or transfer of assets to a potential successor in interest;
Creating de-identified health information; Fundraising for the benefit of Facility; and marketing for which an individual’s authorization is not required.
- The facility will provide the Notices of Privacy Practices at the time of admission or when service is first provided to the individual, whichever is first. In the case of emergency treatment, the facility will provide the notice as soon as reasonably practicable after the emergency treatment.
- The facility must make a good faith effort to obtain a signed acknowledgment from the resident or their responsible party upon request.
- The facility will provide a copy of the written notice to residents and to other people upon request.
- The facility will post a copy of the Notices of Privacy Practices in a clear and prominent location such as the entrance lobby or other similar location.
- A current version of the Notice of Privacy Practices must also be maintained on the facility’s website.
- If there is a material change in the facility’s use and disclosure policy that affects the rights of residents, legal duties imposed, or the privacy practices of the facility, distribute revised notice promptly to current patients. In addition, make the revised notice available upon request and post in a clear and prominent location. Material changes cannot be implemented prior to the effective date of the revised notice.
- Copies of notices issued by the facility will be maintained for at least 6 years from the date of creation of the date when it last was in effect, whichever is later.
- Knowledge of a violation or potential violation of this policy must be reported directly to the Privacy Officer or to the employee hotline.