BGH MISSION STATEMENT:
"Boys & Girls Homes of North Carolina, Inc. is dedicated to providing a comprehensive array of residential and community-based services to meet the needs of vulnerable children by addressing their physical, emotional, social, educational and spiritual development.”
NOTICE OF PRIVACY PRACTICE OF BOYS AND GIRLS HOMES OF NORTH CAROLINA INC.
Effective Date of this Notice:
This Notice of Privacy Practices is effective on January 1, 2011
If you have any questions or request please contact:
Boys and Girls Homes of North Carolina, Inc.
PO Box 127 (400 Flemington Drive)
Lake Waccamaw, NC 28450
Privacy Officer: John Cobb
Boys and Girls Home of North Carolina has the responsibility to respect and maintain the confidentiality of the clients and families that we serve in our programs. Every client and family has the right to privacy and all staff members, foster parents, and volunteers must respect this right. Our clients are especially vulnerable due to their life circumstances, including their lack of permanent family ties and their life histories. It is critically significant that Boys and Girls Home of North Carolina staff members protects the confidentiality surrounding their present and past life experiences
All staff members, including foster parents and volunteers, must follow the policies for the Health Insurance Portability and Accountability Act of 1996 (HIPAA/Compliance Plan). Confidentiality guidelines are listed below. Staff members will receive orientation regarding Confidentiality and Privacy Practices upon hire. They must pass a written test before interaction with clients.
A. The staff members, foster parents, and volunteers will not disclose any information about any client and/or family presently in care, or who has been in care, to anyone except appropriate staff members or those directly involved in the case.
B. Information concerning each client shall be treated as confidential. Designated staff members and foster parents may have access to confidential information as needed in the execution of job-related duties. Caution must be used as to the purpose and manner in which information is shared. Information should be shared as needed and not as idle gossip.
C. Educational information should be shared with the school. Information regarding the client’s family history or past problems may be released with a signed Consent for Release of Information form when the information may be required to assess educational or behavior management needs of the client.
D. A signed Consent for Release of Information form is required when other individuals or agencies have need of confidential information. Information may only be released to those
agencies or individuals referred to in the current Release of Information form signed by the parent or legal custodian. No information shall be released to any person or agency without the approval of the Vice President of Residential Services, or the Vice President of Community Based Services
E. The staff members, foster parent or volunteer will not discuss information or events concerning a client or family in settings where confidential information might be overheard. The staff members, foster parent or volunteer must be careful not to discuss clients or their situations in the presence of other clients, unauthorized staff members, or when guests and visitors are present.
The risk of exposure to confidential information may occur in the course of events within the cottage setting, school setting or in the foster home. Confidential information regarding the client’s family situation should be safeguarded.
F. All records and written material pertaining to a client and family must be properly safeguarded and released only to those specified by the Consent for Release of Information Form.
G. The parent or legal custodian signs a Release of Information form at the time of admission specifying those individuals or agencies to which information may be released. Written records should not be sent to anyone other than those specified.
H. On a daily basis, much written information is passed from one person to another, typed, filed or left on desks. It is important that this information be handled with confidentiality in mind. Staff members, foster parents and volunteers should be careful not to leave information in open view of others. Confidential information will not be left on desks, in unlocked drawers, or in common area printers.
I. Confidential information stored in electronic computer files will be maintained in the client’s medical record folder and files and will not be stored in general access areas of the computer network. Access to client medical record folders and files are limited to involved staff members, foster parents and volunteers.
J. On occasion, programs of Boys and Girls Homes of North Carolina may participate in research projects that are designed to assess specific aspects of the human service field. These projects may be initiated from within our agency, or at other times we may be asked to participate in such projects by other agencies, foundations, and so on. Approval is required from the Board of Directors for any proposal involving past or present clients. Regardless of who initiated or governs the research project, it must be assured that the following criteria will be met.
K. All clients’ rights, as defined in the service manual, must be respected and carefully guarded.
L. Identification by name or picture will be prohibited by research projects outside our own program.
M. Services to the client must not be negatively affected by the demands of the research project.
N. Client participation is completely voluntary, and continued service is not in any way contingent upon participation.
O. Signed informed consent of the client, and parent or legal custodian is to be obtained.
DISCUSSION OF CLIENTS
A. Staff members, foster parents, and volunteers discussing program issues and client cases should make every effort to have such discussions in areas that provide confidentiality, such as offices or specific rooms. These discussions should not occur in hallways, file rooms, reception areas, or other public areas. Staff members, foster parents, and volunteers should remain vigilant to safeguard the confidentiality needs of the clients we serve.
B. Current and former staff members may not initiate contact with current or former clients, including via social media networks.
SECURITY OF CONFIDENTIAL INFORMATION
A. Confidential information will be stored in a secure area in locked, fire-resistant file cabinets. Only authorized employees shall have access to the records of clients if authorized by the appropriate Vice President.
1. Residential Campus: authorized by the Vice President of Residential Services;
2. Community Based Services: authorized by the Vice President of Community Services;
3. Educational Programs: authorized by the Vice President of Residential Services.
B. A staff member will be present in order to explain and protect the record when a client or the parent or legal custodian comes to the agency to review the record.
C. Confidential information that is in an automated data processing system is protected by password access in order to provide a safeguard to ensure controlled access to such information.
ASSURANCE OF CONFIDENTIALITY
A. All employees, clients, volunteers and all other individuals with access to confidential information are required to read and acknowledge by signature the policies regarding confidentiality. In-service training is provided to all individuals with access to confidential information.
B. All individuals shall indicate an understanding of the requirements governing confidentiality by signing a statement of understanding and compliance. Employees and foster parents shall sign such statements upon employment or contractual agreement. Such statements shall contain the following information:
1. Date and signature of the individual and his titles
2. Name of agency
3. Statement of understanding
4. Agreement to hold information confidential
5. Acknowledgment of civil penalties and disciplinary action for improper release or disclosure
INFORMATION RECEIVED FROM OTHER AGENCIES OR INDIVIDUALS
A. Confidential information received from another facility, agency or individual is treated as any other confidential information generated by an external party.
B. Release or disclosure of such information will be governed by agency policy regarding confidentiality.
C. Confidential information other than that generated through Boys and Girls Homes of North Carolina shall not be re-disclosed.
CONSENT FOR RELEASE OF INFORMATION
A. Confidential information will not be released until a signed Consent for Release of Information form has been obtained.
B. Consent for release of information is obtained when a completed Consent for Release of Information form containing the following information is received:
1. client’s name,
2. name of facility releasing the information,
3. name of individuals, agency or agencies to whom information is being released,
4. information to be released,
5. purpose for the release,
6. length of time consent is valid,
7. a statement that the consent is subject to revocation at any time except to the extent that action has been taken in reliance on the consent,
8. signature of the client or the legal custodian, and
9. date consent form is signed.
C. Unless revoked sooner by the client or legal custodian, consent for release of information shall be valid for a period not to exceed one year. Only the client’s legal custodian may sign consent for release of confidential information.
D. Clients who are minors may sign a consent for release of confidential information under the following conditions:
1. When seeking services for venereal disease or other diseases reportable under G.S.130A-134, pregnancy, abuse of controlled substances or alcohol, or emotional disturbances under G.S.90-21.5;
2. When married or divorced;
3. When emancipated by a decree issued by a court of competent jurisdiction;
4. When a member of the armed forces;
5. When consenting for release of information to his/her own attorney.
E. A personal representative of a deceased client may sign the consent of release of information if the estate is being settled, or next of kin of the deceased may sign the consent for release of information if the estate is not being settled.
RE-DISCLOSURE PROTECTION STAMP
A. Whenever information is released, Boys and Girls Homes of North Carolina ensure that each document is stamped with the following statement to ensure that the receiving party fully understands limitation on use/re-disclosure: “Confidential Information, Re-disclosure without client consent is prohibited.” This statement means that information being disclosed to the requesting party from records whose confidentiality is protected by federal law.
B. Federal regulations (42CFR Part 2) prohibit the requesting party from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulation. A general authorization for release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.
RELEASE OF CONFIDENTIAL INFORMATION REGARDING A CLIENT WITH HIV, ARC, OR AIDS
Information relative to AIDS or any related condition is disclosed only in accordance with the communicable disease laws as specified in G.S.130A-143.
RELEASE OF CONFIDENTIAL INFORMATION TO CLIENT RIGHTS COMMITTEE MEMBERS
The Vice President of Residential Services is the delegated employee who may release confidential information upon written consent to the committee members only when members are engaged in fulfilling their function as set for in 10 NAC 26b.0209, and when involved in or being consulted in connection with the treatment of the client.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Congress enacted the Health Insurance Portability and Accountability Act (HIPAA) in 1996 because they recognized the need for national patient record privacy standards. The purpose was twofold, to protect an individual’s rights to view his/her medical records while at the same time protecting that medical information from unauthorized disclosure.
The Insurance Portability and Accountability Act is designed to be a framework, the minimum necessary to assure confidentiality.
We Have a Legal Duty to Protect Health Information about You
We are required by law to protect the privacy of health information about you and that can be identified with you, which we call "protected health information," or "PHI" for short. We must give you notice of our legal duties and privacy practices concerning PHI:
A. We must protect PHI that we have created or received about:
1. your past, present, or future health condition;
2. health care we provide to you; or
3. payment for your health care.
B. We must notify you about how we protect PHI about you.
C. We must explain how, when and why we use and/or disclose PHI about you.
D. We may only use and/or disclose PHI as we have described in this Notice.
This Notice describes the types of uses and disclosures that we may make and gives you some examples. In addition, we may make other uses and disclosures that occur as a byproduct of the permitted uses and disclosures described in this Notice.
If we participate in an "organized health care arrangement" (defined in subsection 2) B below), the providers participating in the “organized health care arrangement" will share PHI with each other, as necessary to carry out treatment, payment or health care operations (defined below) relating to the "organized health care arrangement".
We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first:
A. Posting the revised notice in our offices
B. Making copies of the revised notice available upon request (either at our offices or through the contact person listed in this Notice).
We May Use and Disclose PHI About You Without Your Authorization in the Following Circumstances
A. We may use and disclose PHI about you to provide health care treatment to you.
We may use and disclose PHI about you to provide, coordinate or manage your health care and related services. This may include communicating with other health care and service providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose PHI about you when you need a
prescription, lab work, an x-ray, or other health care services. For example we may use and disclose your PHI when you need a referral for mental health or other health care services.
B. We may use and disclose PHI about you to obtain payment for services.
Generally, we may use and give your medical information to others to bill and collect payment for the treatment and services provided to you by us or by another provider. Before you receive scheduled services, we may share information about these services with your health plan(s). Sharing information allows us to ask for coverage under your plan or policy and for approval of payment before we provide the services. We may also share portions of medical information about you with the following:
1. Billing departments;
2. Collection departments or agencies, or attorneys assisting us with collections;
3. Insurance companies, health plans and their agents which provide you coverage;
4. Utilization departments that review the care you received to check that it and the costs associated with it were appropriate for your illness or injury; and
5. Consumer reporting agencies (e.g., credit bureaus).
EXAMPLE: If you have insurance with ABC insurance, we will report information regarding the medical treatment and services provided to you, along with information supporting the reasons why the medical goods and services were provided, to ABC insurance in order to receive payment.
C. We may use and disclose PHI about you for health care operations.
We may use and disclose PHI in performing business activities, which we call "health care operations". These "health care operations" allow us to improve the quality of care we provide and reduce health care costs. We may also disclose PHI for the "health care operations" of any "organized health care arrangement" in which we participate. An example of an "organized health care arrangement" is the care provided by BGHNC and the therapists who see clients for counseling services.
In addition, we may disclose PHI about you for the "health care operations" of other providers involved in your care to improve the quality, efficiency and costs of their care or to evaluate and improve the performance of their providers. Examples of the way we may use or disclose PHI about you for "health care operations" include the following:
1. Reviewing and improving the quality, efficiency and cost of care that we provide to you and our other patients. For example, we may use PHI about you to develop ways to assist our health care providers and staff in deciding what medical treatment or service provision should be provided to others.
2. Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.
3. Providing training programs for students, trainees, health care providers or non-health care professionals (for example, billing clerks or assistants, etc.) to help them practice or improve their skills.
4. Cooperating with outside organizations that assess the quality of the care others and we provide. These organizations might include government agencies or national accrediting bodies such as the Council on Accreditation and the Teaching-Family Association.
5. Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or specialty. For example, we may use or disclose PHI so that one of our therapists may become certified as having expertise in a specific field of counseling, such as play therapy.
6. Planning for our organization's future operations, and fundraising for the benefit of our organization.
7. Conducting business management and general administrative activities related to our organization and the services it provides.
8. Resolving grievances within our organization.
9. Reviewing activities and using or disclosing PHI in the event that we sell our business, property or give control of our business or property to someone else.
10. Complying with this Notice and with applicable laws.
D. We may use and disclose PHI under other circumstances without your authorization or an opportunity to agree or object.
We may use and/or disclose PHI about you for a number of circumstances in which you do not have to consent, give authorization or otherwise have an opportunity to agree or object. Those circumstances include:
1. When the use and/or disclosure are required by law. For example, when federal, state or local law or other judicial or administrative proceeding requires a disclosure.
2. When the use and/or disclosure are necessary for public health activities. For example, we may disclose PHI about you if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
3. When the disclosure relates to victims of abuse, neglect or domestic violence.
4. When the use and/or disclosure are for health oversight activities. For example, we may disclose PHI about you to a state or federal health oversight agency, which is authorized by law to oversee our operations.
5. When the disclosure is for judicial and administrative proceedings. For example, we may disclose PHI about you in response to an order of a court or administrative tribunal.
6. When the disclosure is for law enforcement purposes. For example, we may disclose PHI about you in order to comply with laws that require the reporting of certain types of wounds or other physical injuries.
7. When the use and/or disclosure are to avert a serious threat to health or safety. For example, we may disclose PHI about you to prevent or lessen a serious and imminent threat to the health or safety of you, or a person or the public.
8. When the use and/or disclosure relate to correctional institutions and in other law enforcement custodial situations. For example, in certain circumstances, we may disclose PHI about you to a correctional institution having lawful custody of you.
E. You can object to certain uses and disclosures.
Unless you object, we may use or disclose PHI about you in the following circumstances:
1. We may share with a family member, relative, friend or other person identified by you, PHI directly related to that person’s involvement in your care or payment for your care. We may share with a family member, personal representative or other person responsible for your care PHI necessary to notify such individuals of your location, general condition, or health.
2. We may share with a public or private agency (for example, American Red Cross) PHI about you for disaster relief purposes. Even if you object, we may still share the PHI about you, if necessary for the emergency circumstances. If you would like to object to our use or disclosure of PHI about you in the above circumstances, please call or write to our contact person listed on the cover page of this Notice.
F. We may contact you to provide appointment reminders.
We may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for treatment or medical care.
G. We may contact you with information about treatment, services, products, or health care providers.
We may use and/or disclose PHI to manage or coordinate your healthcare or service provision. This may include telling you about treatments, services, products and/or other healthcare providers. We may also use and/or disclose PHI to give you gifts of a small value.
EXAMPLE: If you are diagnosed with Attention Deficit Hyperactivity Disorder, we may tell you about nutritional and other counseling services that may be of interest to you.
** ANY OTHER USE OR DISCLOSURE OF PHI ABOUT YOU REQUIRE YOU'RE WRITTEN AUTHORIZATION **
H. Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing by contacting The Privacy Officer. If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures that were being processed before we received your cancellation.
1) You Have Several Rights Regarding PHI About You
A. You have the right to request restrictions on uses and disclosures of PHI about you.
1. You have the right to request that we restrict the use and disclosure of PHI about you. We are not required to agree to your requested restrictions. However, even if we agree to your request, in certain situations your restrictions may not be followed. These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in subsection B.4 of the previous section of this Notice. You may request a restriction by sending it, in writing, to the contact person listed above (on cover sheet).
2. We have the right to limit or deny services in the event you decide to restrict us in the necessary disclosure or your PHI (e.g., the disclosure of information for payment purposes)
B. You have the right to request different ways to communicate with you.
1. You have the right to request how and where we contact you about PHI. For example, you may request that we contact you at your work address or phone number or by email. Your request must be in writing.
2. We must accommodate reasonable requests, but, when appropriate, may condition that accommodation on your providing us with information regarding how payment, if any, will be handled and your specification of an alternative address or other method of contact.
3. You may request alternative communications by a written request to the Human Resources Manager or at the time of admission.
C. You have the right to see and copy PHI about you.
1. You have the right to request to see and receive a copy of PHI contained in clinical, service, billing and other records used to make decisions about you.
2. Your request must be in writing.
3. We may charge you related fees.
4. Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of the PHI about you,
5. If you agree in advance to the form and cost of the summary or explanation, there are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial.
6. You may request to see and receive a copy of PHI by written request to the Human Resources Manager.
D. You have the right to request amendment of PHI about you.
1. You have the right to request that we make amendments to clinical, service, billing and other records used to make decisions about you.
2. Your request must be in writing and must explain your reason(s) for the amendment.
3. We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; or 4) you would not have the right to see and copy the record as described in Section C above.
4. We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial.
5. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment.
6. You may request an amendment of PHI about you by contacting the Human Resources Manager.
E. You have the right to a listing of disclosures we have made.
1. If you ask our contact person in writing, you have the right to receive a written list of certain of our disclosures of PHI about you. You may ask for disclosures made up to six (6) years before your request (not including disclosures made before June 1, 2010). We are required to provide a listing of all disclosures except the following:
i. For your treatment
ii. For billing and collection of payment for your treatment
iii. For health care operations
iv. Made to or requested by you, or that you authorized
v. Occurring as a byproduct of permitted uses and disclosures
vi. Made to individuals involved in your care, for directory or notification purposes, or for other purposes described in subsection B.5 above
vii. Allowed by law when the use and/or disclosure relates to certain specialized government functions r or relates to correctional institutions and in other law enforcement custodial situations (please see subsection B.4 above) and
viii. As part of a limited set of information which does not contain certain information which would identify you.
2. The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information.
3. If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee. You may request a listing of disclosures by making a written request to the Human Resources Manager.
A. You have the right to a copy of this Notice.
1. You have the right to request a paper copy of this Notice at any time by contacting the Human Resources Manager at BGHNC. Please keep this copy and only submit the last sheet with signatures.
2. BGHNC will provide a copy of this Notice no later than the date you first receive service from us (except for emergency services, and then we will provide the Notice to you as soon as possible).
2) You May File A Complaint About Our Privacy Practices
A. If you think we have violated your privacy rights, or you want to complain to us about our privacy practices, you can contact the person listed below:
Boys and Girls Homes of North Carolina, Inc.
P.O. Box 127
Lake Waccamaw, NC 28450
Privacy Officer: John Cobb
(910)646-3083 ext 215
B. You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. If you file a complaint, we will not take any action against you or change our treatment of you in any way.
3) Effective Date of this Notice
This Notice of Privacy Practices is effective on January 1, 2011