PRIVACY POLICY
Confidentiality/HIPAA
The purpose and importance of confidentiality rules and laws are for the Center to protect each consumer's right to privacy. Confidentiality rules and laws are followed to safeguard the consumer's best interests and to guide Center employees in their work so that the best possible services can be provided. The expectation is that all Center employees will keep all information confidential unless disclosure is necessary to prevent serious, foreseeable and imminent harm to a consumer. In all instances of disclosure without consent, only information that is directly relevant to the purpose for which the disclosure is made will be revealed.
All mental health treatment information is strictly confidential. The Center will protect the confidentiality of all information its records at all stages of collection, use, storage, disclosure and destruction. A client record includes all written clinical information, observations, reports, or fiscal documents relating to a prospective, present, or past client, when the creation or retention of those documents is either required or authorized as part of operations of the Center. It includes central records, individual client records, and reports that may be created.
It is essential that employees safeguard the confidential nature of information of Center clients. Employees must use caution and discretion in using and sharing information. No employee (or student) shall disclose client information to outsiders, including other clients, third parties or members of one's own family.
The policy of confidentiality applies with equal force to client affairs and employee affairs. Any disclosure of confidential information may result in disciplinary action up to and including termination.
It is the policy of the Center for Autistic Children that clinical records are the property of the Center and shall be current and accurate.
Clinical records are only accessible on a need to know basis and may not be duplicated, removed from the facility or discussed outside the facility.
Anyone who is entrusted with a clinical record is responsible for safeguarding the information in the record against loss, defacement, tampering, or use by unauthorized persons.
Except as required by law, the written consent of the client, parent, family or other legally responsible parties is required for the release of clinical record information.
Charts
All material contained within client's charts, when not under the direct supervision of the person using them, are to be kept in a locked secure area. This includes all levels of materials. Locked secure areas are contained within the staff office, the room behind the font desk, room 105, and room 120.
Charts must be signed out up front - the location of every chart must be known at every moment. The client or the client's parents have a legal right to view the contents in a timely manner.
When the chart is not in front of you, it should be locked up. The filing cabinet in the back staff office should be locked (essentially between the hours of 9 AM - 2 PM and 4:30-8:30 AM).
Center clients and/or the parent(s)/guardian(s) have access to client charts for review. The client/guardian may make suggested revisions to the chart. The suggested revisions become part of the record but do not result in a change to the original records. Review of client charts occurs in the presence of the Center's Clinical Director, Outpatient Coordinator or Social Worker. The client and or the parent(s)/guardian(s) have access to all filed or unfiled progress notes.
Original records
All original information must be included in the client's chart and filed in the file room. While duplicates may be kept for convenience, they must be kept in a locked filing cabinet.
Client/guardian assess to the staff office
Clients and/or parents should not be in the staff office.
Students
All students (internship or practicum) who work with a Center client have access to client's charts only when the Office Manager has been notified in writing that the student has access to a particular chart. The student must request the chart from the Office Manager, who verifies access and signs the chart out to the student. The Program Assistant monitors all student requests for PHI (confidential material) to determine that they are on their caseload.
Personal notes of students/interns should not contain information that is considered confidential or identifies the client. Should the student write a personal note that contains this information, the student is not allowed to keep their notes or remove the notes off-site. The notes must be included in the client's chart. Students may only retain their personal notes, if all identifies and confidential material is removed.
Communication boards
Communication boards in therapy rooms and staff office should utilize client's initials. Use of first names with or without initial of last name (duplicate first names) and photographs of the clients are used to create visual schedules in the treatment rooms and are a necessary part of treatment and is compliant with HIPAA.
Photographs
Use of Photographs: Photographs of children are taken (without written consent) for treatment purposes and for special Public Relations events (with written consent specific to the purpose). It is highly recommended that only the Center's camera be used to take pictures of the children. However, if you choose to use your personal camera, all photographs and negatives are the property of the Center. Only pictures of children that have been given to you personally by the parent may go home with you. In the event of a parent requesting (or coming to the Center with a camera) to take a picture of their child (with other children), they may not do so without the expressed permission of the other child's guardians.
Incident reports
Incident reports which are sent home, only identify the name of the child who was injured.
Telephone Usage
The use of cellular/cordless phones to have conversations with parents is prohibited. You must use a land phone to have a confidential conversation with parents. If you know a client/'guardian is using a cell phone or a cordless phone (i.e., you don't have to ask) you should do the following:
- Ask the client/guardian if they have a land phone.
- Advise the client/guardian that the conversation is no longer confidential.
- Should the client/guardian wish to continue the conversation, caution the client/guardian.
- Document in your progress notes that the parent wished to remain on the telephone.
Verification of client of guardian
All staff has the responsibility to be certain that they are speaking with the client or to the parent/guardian of client. If there is ever uncertainty or confusion regarding the identity, the staff must verify their identity by requesting identification. At times, other members of the family (grandparents, etc.) may visit the Center or otherwise attempt to engage you in matters regarding the child. While you may make a general, but limited statement, such as "he's doing well", you are unable to provide any specifics without breaching confidentiality.
Family Consultants
Family consultants who are employed by the Center may remove confidential client material from the Center under the following conditions:
- Removal is only over night for the scheduled home/site visit.
- The information removed is limited to copies of the treatment plan, recent psychiatric evaluation, most recent progress notes and verification signature page of client/guardian.
- No originals of treatment plans or psychiatric evaluations may leave the building. On the records pertaining to the client may enter the home (i.e., no other client record).
Student Research Projects
The Center requires all research projects to gain IRB approval, following approval by the Center's Research Committee.
E-mail
Employees are not allowed to e-mail PHI. Employees are not allowed to offer treatment advice via e-mail.
Fax
Employees are allowed to fax PHI provided the fax number has been verified.