To establish clear, appropriate and acceptable confidentiality of Protected Health Information (PHI) and all aspects of confidentiality, and to establish and maintain processes and resources for reporting, investigating, and resolving potential violations of applicable Federal and State laws within the organization.
It is the policy of Keys To Tranquility (KTT) to establish a mechanism to protect the confidentiality of individual identifiable member health and financial information from any unauthorized intentional or unintentional use or disclosure in accordance with the requirements set forth in HIPAA 45 CFR 164.
Protected Health Information (PHI) – Any individually identifiable health or financial information, whether verbal, written, electronic, or otherwise recorded in any form or medium that is:
The Federal Privacy Regulations further specify that the following 17 pieces of “Individually Identifiable Information” that, when linked with health or medical information, constitutes PHI (45 CFR 164.514):
Protected Health Information may not be released without a complete and valid written consent or authorization signed by client, parent or legally authorized representative unless a release of the PHI is specifically allowed by State and Federal law without a valid authorization.
Confidentiality Statement: All KTT staff is required to sign the KTT Confidentiality Statement before they are granted access to PHI.
All KTT employees that suspect, discover, or receive a report of PHI violations from another party have the obligation to report that violation in writing, in person, or by telephone to a supervisor, the Vice President, or anonymously.
Any personnel or contractors that report a violation should discuss the situation only with direct supervisors or the Vice President to ensure that confidentiality of the affected area/individuals can be maintained.
For supervisors that receive notice of a potential violation, this is to be communicated to the Vice President within twenty-four (24) hours. The supervisor should not discuss the violation with other parties.
When the Vice President receives a report of a potential violation, he/she will then prepare a confidential corporate compliance report (if one has not been completed yet). The Vice President will then conduct an initial investigation based on the report and coordinate with legal counsel if necessary.
To assure the protection of all client rights to privacy and define the process through which Federal Confidentiality Guidelines are implemented.
Confidentiality is a fundamental component of quality clinical services. It is therefore the policy of Keys To Tranquility to safeguard the client right to privacy with respect to confidential information disclosed or revealed in the therapeutic setting.
In order to insure that client confidentiality is protected, upon employment all staff members of KTT will be required to review Federal Confidentiality Regulations relating to the “Confidentiality of Alcohol and Drug Abuse Patient Records,” and other confidentiality laws that may be applicable at that time. After having reviewed said laws and regulations, the employee will be required to sign a statement acknowledging their understanding of this material, the implications contained therein, and that the employee agrees to abide by all applicable confidentiality and privacy regulations. A copy of this signed statement will be included in each employee’s personnel file.
Federal Confidentiality Regulations, 42 CFR Part 2 “Confidentiality of Alcohol and Drug Abuse Patient Records,” will define the basic framework within which all operating policies and practices of KTT are to be conducted. Any exceptions to the contents of this policy are to be enacted only in accordance with relevant clauses contained within the Federal Confidentiality Regulations, and then only upon approval of the President. In the absence of the President, the Program Director will make such determinations as may be necessary.
The full text of the most recent Federal Confidentiality Regulations will be available through the Vice President. In summary, these regulations state:
Any violation of client confidentiality, or knowledge of such violation, shall be immediately reported to the affected employee’s direct supervisor; who will immediately inform the Vice President.
Violation of client confidentiality by a staff member will result in disciplinary action that may include termination of employment. Violation of one client’s confidentiality by another client may result in termination of services to the client who initiated the breach.
With the exception of situations previously referenced in this policy, and more fully described in the Federal Confidentiality Regulations, confidential information held by Keys To Tranquility may only be released or disclosed if the client in question has properly executed an “Authorization to Use and Disclose Protected Health Information” form. Said information to be released or disclosed may include only information accumulated through the client’s involvement with KTT Reports from other organizations may be released only by the organization from which the report originated, unless the client has signed a specific “Authorization to Use and Disclose Protected Health Information” form that allows KTT to re-disclose such information.
“Authorization to Use and Disclose Protected Health Information” forms shall contain the following information:
Confidential client information may be disclosed among employees of the different departments comprising KTT only to the extent necessary for said employees to perform the expected functions of their employment. Graphically illustrated, confidential client information may be disclosed within a department and upwardly within the agency’s internal table of organization. All other internal disclosures shall be limited to the extent necessary for the performance of one’s position responsibilities.
Information to be released to other organizations must be disclosed only in accordance with this policy, and with the best interest of the client as a paramount factor. Such disclosures will contain only that information necessary to satisfy the professional obligations of KTT Disclosure of incidental information shall be avoided whenever possible.
Authorized disclosures of confidential client information to other organizations will be conducted by the clinician who is primarily responsible for the treatment of said client. If this is not possible or prudent, the Vice President shall oversee the disclosure of confidential client information.
Confidential records are to be maintained in locked quarters within the agency at all times or secured electronically and password protected using the EMR system (KIPU).
In accordance with state law with regards to confidentiality, a client may request information pertaining to their clinical record. Said request should be submitted in writing to either the Clinical Director or the Vice President. Any information to be released shall include only elements detailed in the Release of Information Policy.
Keys To Tranquility
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Treatment, payment and health care operations:
Keys To Tranquility (hereinafter Keys To Tranquility) uses and discloses your protected health information for treatment, payment, and health care operations. Some examples of when our office may use or disclose your health care information for these purposes include:
Other uses and disclosures:
Keys To Tranquility may also use or disclose your protected health information, in compliance with guidelines outlined by law, for the following purposes:
Authorization for other uses: Keys To Tranquility will make other uses and disclosure of your protected health information only after obtaining your written authorization. If you authorize a use not contained in this notice, you may revoke your authorization at any time, by notifying us in writing that you wish to revoke your authorization.
Your rights regarding the privacy of your health information: Subject to limitations outlined by law, you have certain rights related to use and disclosure of your protected health information, including the right to:
Keys To Tranquility duties regarding the privacy of your health information:
Subject to limitations outlined by law, Keys To Tranquility has certain duties related to your protected health information, including: