1. PURPOSE

 The purpose of this policy is to establish guidelines concerning the right to privacy and record confidentiality of individuals receiving services.

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II. POLICY

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All individuals have the right to be treated with full recognition of their dignity, which includes privacy for personal care and treatment and the right to have their records treated in a confidential manner. The  Owner will exercise the responsibility and duties of the "responsible authority" for all program data, as defined in the Minnesota Data Practices, Minnesota Statute Chapter 13. The company will also follow guidelines for record confidentiality as set forth in the Health Insurance Portability and Accountability Act (HIPAA).

 

III. PROCEDURE

 

    A.  Each individual receiving services will be afforded privacy for personal care and treatment.  

                1.  Personal cares or treatments requiring privacy will only be carried out in private areas, such as a bathroom or bedroom, with doors  and/or curtains closed. Employees will assist individuals in discerning when privacy                          is necessary. Employees will always honor a request by the individual and/or legal representative for privacy with any personal cares or treatments.

              2. Each individual will be allowed privacy while engaging in personal activities, unless assistance by employees is required by the Risk Management Plan, Individual Service Plan, or for other reasons of                       safety and assistance.

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     B.  Each individual receiving services will be treated with full recognition of their dignity including, but not limited to:

              1.  Individuals will be provided privacy when talking on the telephone unless indicated otherwise in their Risk Management Plan, Individual Service Plan, or Consumer Rights.

              2.  Individuals and their guests will be provided with privacy during visits, taking into consideration the Risk Management Plan and the rights of other individuals receiving services.

              3.  Employees will knock on opened or closed doors before entering unless there is reasonable concern that an individual’s health or safety is at risk.

              4.  Employees will wait for permission to enter an individual’s private living spaces until permission is granted, if the individual is capable. 

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     C.  Access to individual program information in written or oral format is limited to authorized persons.

1. The following persons may have immediate access to individual program information

   1. The Owner

   2. The Designated Coordinator

   3. Assigned nurse or nurse consultant

   4. The individual receiving services

   5. Legal representative

   6. Case manager

2. Upon request, employees will provide individual file information to the following employees of entities or agencies who are authorized by Minnesota Statutes Chapter 13 or federal law:

   1. Minnesota Department of Human Services

   2. County of Financial Responsibility or the County of Residence’s Social Services

   3. The Ombudsman for Mental Health or Developmental Disabilities

   4. US Department of Health and Human Services

   5. Social Security Administration

   6. County, state, or federal auditors

   7. Adult or Child Protection units

3. Employees, sub-contractors, Internal Review Committee members, or consultants of the company will consider information about individuals or their families private. The information may not be released except as authorized.

4. Employees will have access to private data only to the extent necessary to carry out their duties.

5. Entities or individuals who have obtained written authorization from the individual and/or legal representative have access to written and oral information as detailed within that authorization.

6. Information will be released to law enforcement or judiciary agencies only upon completion of a written authorization or through a valid court order.

7. Employees receiving telephone calls from someone claiming to know an individual receiving services or to have consent to obtain information, will not acknowledge whether someone is an individual receiving services or release information without a signed authorization.

8. Information will be disclosed without prior consent only when necessary in a medical emergency requiring immediate treatment or action and the individual and/or legal representative is unable to provide consent or when disclosure is necessary to protect against a clear and substantial risk of imminent harm. The Owner will ensure the documentation of the following:                                                                   

1. The nature of the emergency

2. The type of information disclosed

3. To whom the information was disclosed

4. How the information was used to respond to the emergency

5. When and how the individual and/or legal representative was informed of the disclosed information

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 9.   The Owner will ensure that all program information, including electronic information is secure and under employees direct control at all times. Files will not be removed from the program site without                valid reasons.

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10.  Employees will not write the names of other individuals receiving services from any agency on documents to be placed in an individual’s record. Any documentation regarding a report of alleged                              maltreatment will be filed separately.

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D.  The service initiation process will comply with the right to privacy of records.

1. The Owner will ensure that referral information for individuals is authorized through the referring agency.

2. Upon service initiation, the Designated Coordinator will distribute and explain the right to privacy to the individual and/or legal representative.         

3. The Designated Coordinator will ensure completion of all required authorizations including, but not limited to the:

   1. Financial assistance agreement

   2. Consent to act in an emergency

   3. Authorization to administer medication

   4. Consent to the release of a photograph

4. If the individual and/or legal representative does not give authorization, the Designated Coordinator will attempt to negotiate a limited version of the authorization. If no agreement is made, the Designated Coordinator will confer with the case manager to discuss if ongoing service provision is possible.

 

E.  The individual and/or legal representative has the right to request that written documentation be altered.

1. If the individual and/or legal representative objects to the accuracy of any information, they will be asked to put their objections in writing with an explanation as to why the information is incorrect or incomplete.

2. The Owner who will make a decision in regards to any possible changes.

3. A copy of the written objection will be retained in the individual’s file.

4. If no changes are made and distribution of the disputed information is required, the Owner will ensure that the objection accompanies the information as distributed, either orally or in writing.

5. If the individual and/or legal representative disagrees with the resolution of the issue, they will be encouraged to follow the procedures outlined in the Policy and Procedure on Individual Grievances.