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NOTICE OF PRIVACY PRACTICES

THIS NOTICE, IN COMPLIANCE WITH FEDERAL PRIVACY REGULATIONS, DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Aging with Comfort is required by law to maintain the privacy of protected health information and to provide you adequate notice of your rights and our legal duties and privacy practices with respect to the uses and disclosures of protected health information (45 CFR § 164.520). The agency maintains a record (paper/electronic file) of the information we receive and collect about you and of the care we provide to you.

We have summarized our responsibilities and your rights on this first page. For a complete description of our privacy practices, please review this entire notice.

 

Our Responsibilities

Our Agency is required to:

• Maintain the privacy of your health information.
• Provide you with this notice of our legal duties and privacy practices with respect to information we collect and maintain about you.
• Abide by the terms of this notice.
• Notify you following a breach of unsecured protected health information.

 

Your Rights

As a Consumer of Aging with Comfort, you have several rights with regard to your health information, including the following:

• The right to request that we not use or disclose your health information in certain ways.
• The right to request to receive communications in an alternative manner or location.
• The right to access and obtain a copy of your health information.
• The right to request an amendment to your health information.
• The right to an accounting of disclosures of your health information.

We reserve the right to change our privacy practices and to make the new provisions effective for all health information we maintain. Should our privacy practices change, we will provide you or your authorized representative a copy of our revised Notice of Privacy Practices, as well as post a copy of the revised Notice of Privacy Practices on our website. A copy of the revised notice will be available after the effective date of the changes upon request.

We will not use or disclose your health information without your authorization, except as described in this notice. Thus, for example, we will require your authorization before we would use or disclose your protected health information for marketing purposes, and we will not sell your health information without a specific authorization from you.

If you have questions and would like additional information, you may contact our Agency’s Privacy Officer, the Director, at (866) 478-4751.

 

Understanding Your Health Record/Information

Each time you receive services from Aging with Comfort, a record is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• basis for planning your care and treatment;
• means of communication among the many health professionals who contribute to your care;
• legal document describing the care you received;
• means by which you or a third-party payer can verify that services billed were actually provided;
• a tool in educating health professionals;
• a source of data for medical research;
• a source of information for public health officials who oversee the delivery of health care in the United States;
• a source of data for Agency planning and marketing; and
• a tool with which we assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

 

How We Will Use or Disclose Your Health Information

• Treatment. We will use or disclose your health information for treatment purposes, including for the treatment activities of other health care providers. For example, information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. That way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you.
• Payment. We will use or disclose your health information for payment, including for the payment activities of other health care providers or payers. For example, a bill may be sent to you or a third-party payer, including Medicare or Medicaid. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
• Health care operations. We will use or disclose your health information for our regular health operations. For example, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.

In addition, we will disclose your health information for certain health care operations of other entities. However, we will only disclose your information under the following conditions: (a) the other entity must have, or have had in the past, a relationship with you; (b) the health information used or disclosed must relate to that other entity’s relationship with you; and (c) the disclosure must only be for one of the following purposes: (i) quality assessment and improvement activities; (ii) population-based activities relating to improving health or reducing

health care costs; (iii) case management and care coordination; (iv) conducting training programs; (v) accreditation, licensing, or credentialing activities; or (vi) health care fraud and abuse detection or compliance.

• Business associates. There are some services provided through the use of outside people and entities. Examples of these “business associates” include our accountants, consultants, and attorneys. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require the business associates to appropriately safeguard your information, which they are also required to do by law.
• Notification. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care and general condition. If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided us, g., on an answering machine.
• Communication with family. We may disclose information to a family member, other relative, close personal friend or any other person involved in your care or in payment for your care.
  If appropriate, these communications may also be made after your death, unless you have instructed us not to make such communications.
• Research. We may disclose information to researchers when certain conditions have been met.
• Transfer of information at death. We may disclose health information to funeral directors, medical examiners, and coroners to carry out their duties consistent with applicable law.
• Organ procurement organizations. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
• Marketing. We may contact you regarding your treatment, to coordinate your care, or to direct or recommend alternative treatments, therapies, health care providers or settings. In addition, we may contact you to describe a health-related product or service that may be of interest to you, and the payment for such product or service.
• Food and Drug Administration (FDA). We may disclose to the FDA, or to a person or entity subject to the jurisdiction of the FDA, health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
• Workers’ Compensation. We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to Workers’ Compensation or other similar programs established by law.
• Public health. As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
• Correctional institution. Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
• Law enforcement. We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
• Reports. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more individuals, workers or the public.

 

Your Health Information Rights

Although your health record is the physical property of Aging with Comfort, the information in your health record belongs to you. You have the following rights:

• You may request that we not disclose your health information for a particular reason related to treatment, payment, general health care operations, and/or to a particular family member, other relative or close personal friend. We ask that such requests be made in writing on a form provided by our Agency. Although we will consider your request, please be aware that we are under no obligation to accept it or to abide by it, unless it is a request to prohibit disclosures to your health care plan relating to a service for which you have already paid in full out of pocket. For more information about this right see 45 Code of Federal Regulations (C.F.R.) §164.522(a).
• If you are dissatisfied with the manner in which or the location where you are receiving communications from us that are related to your health information, you may request that we provide you with such information by alternative means or at alternative locations. Such a request must be made in writing and submitted to Aging with Comfort. We will attempt to accommodate all reasonable requests. For more information about this right, see
  45 C.F.R. §164.522(b).
• You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the timeframes established by law. You may make such requests orally or in writing. However, in order to better respond to your request, we ask that you make such requests in writing on our Agency’s standard form. If you request to have copies made, we will charge you a reasonable fee. For more information about this right, see 45 C.F.R. §164.524.
• If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing and must provide a reason to support the amendment. We ask that you use the form provided by our Agency to make such requests. For a request form, please contact the Compliance Department, at (267) 433-4601. For more information about this right, see 45 C.F.R. §164.526.
• You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request (not to exceed 6 years). We ask that such requests be made in writing on a form provided by our Agency. Please note that an accounting will not apply to any of the following types of disclosures: disclosures made for reasons of treatment, payment, or health care operations; disclosures made to you or your legal representative, or any other individual involved with your care; disclosures made pursuant to a valid authorization; disclosures to correctional institutions or law enforcement officials; and disclosures for national security purposes. You will not be charged for your first accounting request in any 12-month period. However, for any requests that you make thereafter, you will be charged a reasonable cost-based fee. For more information about this right, see 45 C.F.R. §164.528.
• You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.
• You may revoke an authorization to use or disclose health information, except to the extent that action has already been taken. Such a request must be made in writing.

 

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact (267) 433-4601.

If you believe that your privacy rights have been violated, you may file a complaint with us. These complaints must be filed in writing on a form provided by our Agency. The complaint form may be obtained from Aging with Comfort and when completed should be returned to 8302 Bustleton Avenue, Philadelphia, PA 19152 You may also file a complaint with the Secretary of the Department of Health and Human Services. There will be no retaliation for filing a complaint.

 

Confidentiality of Information/HIPAA 

The HIPAA Privacy Rule became effective April 14, 2001 and was amended on August 14, 2002 to ensure that the consumer’s right to privacy is protected; to create national standards to protect medical records and other protected health information (PHI); and to set a minimum standard of health information safeguards. Aging with Comfort and its personnel will maintain confidentiality of consumer records and consumer information.  Uses and disclosures of protected health information will be carried out according to Aging with Comfort policies and procedures and applicable law.

OVERVIEW TO POLICY:

1. Consumer records must be kept confidential and, except in emergencies, may not be accessible to anyone without the written consent of the participant or if a court orders disclosure other than the following:
   1. The consumer
   2. The consumer’s legal guardian
   3. The agency’s staff for the purpose of providing a service to the consumer
   4. An agent of the Department of Human Services
   5. An individual holding the consumer’s power of attorney for health care or health care proxy.

2. Relative to agency staff:
   1. Only personnel involved in the service or supervision of services will have access to consumer records.
   2. Personnel will not discuss consumer information outside the context of professional conversation regarding the consumer’s status.
      
      
3. Only personnel involved in the service or supervision of services will have access to consumer records. Consumers will be informed, at the time of admission, of their responsibility to maintain the confidentiality of records maintained in their homes.
4. Consumer records will not be released to third-party persons without written authorization from the consumer.
5. A Consumer Service Agreement which refers to the Consumer Bill of Rights and the right to privacy and confidentiality regarding the disclosure of protected health information will be signed by the consumer upon admission to Aging with Comfort.
6. Release of information for purposes other than for consumer care, as directed by the consumer or as required by law or regulation, must have a separate consumer authorization. Appropriate information will be forwarded with a valid authorization.
7. Requests for consumer information will be reviewed by the Director to determine if this information can be released. Requests for information that may not be released will be forwarded to the Director.
8. Copies of consumer records will not be removed from Aging with Comfort except by subpoena, by requirement of statutory law, or by written authorization of the agency. Confidential information will be forwarded in an envelope designated “confidential”.
9. Consumers will be allowed access to their consumer records at Aging with Comfort during office hours after giving reasonable notice to the Director or designee.
10. Consumer records will be kept in a locked cabinet or room when not in use. The Director or designee will be responsible for the key. Unauthorized individuals will not be allowed access to consumer records.
11. The following consumer information will be secured after business hours:
    1. Consumer records
    2. Consumer intake information
    3. Minutes of consumer service meetings
    4. Quality Management data
    5. Notes prior to filing in the consumer record

12. Information contained in quality management/performance improvement reports will not specify individual consumer or employee information.
13. On the first day during the orientation process, this confidentiality policy will be reviewed with Aging with Comfort personnel.
14. Aging with Comfort personnel will sign a Confidentiality Agreement/HIPAA Compliance during orientation (see attached).
15. A breach in confidentiality by Aging with Comfort personnel is grounds for possible employment termination.

 

PROCEDURE:

Aging with Comfort and its personnel will maintain confidentiality of consumer records and consumer information.  Uses and disclosures of protected health information will be carried out according to Aging with Comfort policies and procedures and applicable law.

The HIPAA Privacy Rule prohibits disclosure of PHI except in accordance with the regulations; with all organizations having access to PHI needing to do an analysis to determine:

1. Use and disclosure for treatment, payment and healthcare operations;
2. Use and disclosure with individual authorization; and
3. Use and disclosure without authorization for specified purposes.
   
   

Under HIPAA Privacy Regulations, Aging with Comfort is required to:

1. Appoint a privacy officer charged with creating a comprehensive Privacy Policy.
2. Develop minimum necessary policies.
3. Amend Business Associate contracts.
4. Develop accounting of disclosure capability.
5. Develop procedures to request alternative means of communication.
6. Develop procedures to request restricted use of PHI.
7. Develop complaint procedures.
8. Develop amendment request procedures.
9. Develop individual access procedures.
10. Develop an anti-retaliation policy.
11. Train the workforce.
12. Develop and disseminate the Privacy Notice.

As a Business Associate of the Department of Human Services (Department), Aging with Comfort must appropriately safeguard PHI in accordance with HIPAA requirements and:

1. Appropriately safeguard PHI.
2. Report any misuse of PHI.
3. Secure satisfactory assurances from any subcontractor.
4. Grant individuals access to and the ability to amend their PHI.
5. Make available an accounting of disclosures.
6. Release applicable records to the covered entity and the Secretary of Health and
   Human Services.
7. Upon termination of the Business Associate relationship, return or destroy PHI.

Specific elements of the HIPAA Private Practice Notice include:  

1. Header: “This notice describes how medical information about you may be used and how you can get access to this information. Please review it carefully.”
2. A description, including one example of the types of uses and disclosures the covered entity
   may make for treatment; payment of health care operations.
3. Description of each of the other purposes for which the covered entity is required or permitted to use or disclose individually identifiable health information without consent or authorization.
4. If appropriate, a statement that the covered entity will contact the individual to provide information about health-related benefits or services.
5. A statement of the individual’s rights under the privacy regulations.
6. A statement of the covered entity’s duties under the privacy regulations.
7. A statement informing individuals how they may complain about alleged violations of the privacy regulations.

Employee Training and Privacy Officer Appointment

Aging with Comfort trains their employees in the privacy procedures and designates the Director as the Privacy  Officer as the individual responsible for ensuring that privacy procedures are followed.

Consent and Authorization

Consent

The HIPAA Privacy regulations permit (not require) a covered entity to obtain a consent from a consumer to use and disclose PHI for care, payment, and home care operations.

Authorization

Covers any individual’s disclosure that is not for care, payment, or home care operations, or exempted under regulations. The authorization used by Aging with Comfort in compliance with regulations:

1. Clearly and specifically describes the information that may be disclosed;
2. Provides the name of the person or entity authorized to make the disclosure;
3. Provides the name of the person or entity to whom the information may be disclosed;
4. Contains an expiration date or event;
5. Contains a statement that the authorization may be revoked in writing;
6. Contains a statement that the information may be subject to re-disclosure;
7. Is signed and dated.
   
   

Consumer

The U.S. Department of Health and Human Services Office for Civil Rights (OCR), not the Department, is responsible for enforcing HIPAA privacy requirements by:

1. Conducting compliance review;
2. Providing technical assistance to covered entities to assist them in achieving compliance with technical assistance;
3. Responding to questions and providing guidance;
4. Investigating complaints; and when necessary,
5. Seeking civil monetary penalties and making referrals for criminal prosecution.
   
   

Aging with Comfort Compliance Process

1. Only personnel involved in the service or supervision of services will have access to consumer records. Consumers will be informed, at the time of admission, of their responsibility to maintain the confidentiality of records maintained in their homes.
2. Personnel will not discuss consumer information outside the context of professional conversation regarding the consumer’s status.
3. Consumer records will not be released to third-party persons without written authorization
   from the consumer.
4. A Consumer Service Agreement, which refers to the Consumer Bill of Rights and the right to privacy and confidentiality regarding the disclosure of protected health information, will be signed by the consumer upon admission to Aging with Comfort.
5. Release of information for purposes other than for consumer care, as directed by the consumer or as required by law or regulation, must have a separate consumer authorization. Appropriate information will be forwarded with a valid authorization.
6. Requests for consumer information will be reviewed by the Director to determine if this information can be released. Requests for information that may not be released will be forwarded to the Director.
7. Copies of consumer records will not be removed from Aging with Comfort except by subpoena, by requirement of statutory law, or by written authorization of the agency. Confidential information will be forwarded in an envelope designated “confidential”.
8. Consumers will be allowed access to their consumer records at Aging with Comfort during office hours after giving reasonable notice to the Director or designee.
9. Consumer records will be kept in a locked cabinet or room when not in use. The Director or designee will be responsible for the key. Unauthorized individuals will not be allowed access to consumer records.
10. The following consumer information will be secured after business hours:
11. Consumer records
12. Consumer Intake information
13. Minutes of consumer service meetings
14. Performance improvement data
15. Notes prior to filing in the consumer record
16. Information contained in performance improvement reports will not specify individual consumer or employee information.
17. On the first day during the orientation process, this confidentiality policy will be reviewed by
    Aging with Comfort
18. Aging with Comfort personnel will sign a confidentiality statement during orientation.
19. A breach in confidentiality by Aging with Comfort personnel is grounds for possible employment termination.