HIPAA, Abuse

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HIPAA, Abuse Neglect, JCAHO

• PHS Policies/Practices for New Employee -
  Self-Study
• Contact Yvette McMiller, Operations (919)
  537-7490

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WELCOMEThis Self-Study has 3 Sections

• I. HIPAA Explains PHS Privacy Practices and
  Confidentiality Guidelines
• II. Abuse and Neglect Describes PHS Abuse and
  Neglect Policy for Child, Elder and Domestic
  Partner Abuse
• III. Joint Commission (aka JCAHO) Brief
  Introduction to the Joint Commission experience
  at PHS

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I. HIPAA Objectives

• By the end of this section you will be able to
• Describe the HIPAA Law Background
• Identify What is Protected Health Information
• State How a Patient Consents to Disclosure of
  their Protected Health Information
• Describe the PHS Confidentiality Guidelines
• Give examples of routine Disclosure of Patient
  Information for Treatment, Payment, Operations
• State Limitations of Disclosures Without Consent
• Discuss Patient Rights and Special Requests

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HIPAA Health Insurance Portability and
Accountability Act

• In 1996, the HIPAA Law, Part I, came into effect
  it was designed for employees to be able to
  carry their health insurance without losing
  coverage between jobs This is called
  Portability.
• Were you offered the option to continue your
  health insurance after you left your previous
  employment??
• -This now happens all over the USA, HIPAA
  requires it!
• The HIPAA Law had various parts. Part II
  involved Administrative Simplifications, so that
  information could be handled easily
  electronically. Concerns about privacy were
  addressed in Part II in a section called the
  Privacy Rule, which went into effect in April
  2003.
• The Privacy Rule standardized health information
  privacy across all states
• Previously, individual state laws governed what
  took place. FYI - This was the first time in
  history that state laws were adopted by the
  Federal Government instead of vice versa.
• The Privacy Rules are minimum standards, which
  means practices can be stricter but never more
  lenient than what is in the law.
• Most people refer to HIPAA thinking about the
  Privacy Rule part of the Law

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HIPAA Acronyms to know for discussion

• PHI Protected Health Information Any
  identifiable health information that can be
  traced to an individual patient
• Examples Name, Address, Phone, Date of Birth,
  Photo, Voice Recording, E-mail address
• We all know people who just by their voice, we
  can tell who they are. What if you heard
  somebody you knew on a radio show about a clinic?
  If they had not consented to the voice recording
  disclosure, it would be a privacy invasion
  violation of HIPAA.
• TPO Treatment, Payment, Operations Patients
  consent at registration for routine disclosure of
  their PHI, that is necessary for
• Treatment Such as for Referrals and Transfers
  we give PHI to refer
• Payment We give PHI to Insurance Companies,
  Medicaid, Medicare, so we can be paid
• Operations Examples - we use PHI in Quality
  Audits, Investigating Grievances, and Developing
  Training - all part of operating a practice

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Piedmont Health Services Health Information
Privacy Practices

• Notice of Information Privacy Practices
• All patients are offered the Notice of Privacy
  Practices at Registration
• The format is simple
• It comes in Spanish and English
• It lists how PHS can disclose PHI
• It lists patient rights

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Piedmont Health Services (PHS) Confidentiality
Guideline

• PHI will not be discussed
• outside work
• when not related to patient care
• in areas audible to other patients/staff
• You see somebody at the grocery store who you
  saw as a patient yesterday. Do you approach them?
  No. Just smile, let them approach you some
  people do not want others to know they were at
  the providers office.
• What do you do when you overhear two staff
  talking about a patient where others can hear??
  Tell your supervisor or any supervisor nearby
  we must refrain from talking about PHI in public
  areas as much as possible.

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Confidentiality Guideline Ctd

• Release if PHI is only with signed Authorization
• Initial release for TPO is signed at Registration
  that covers most releases, so a new
  authorization is usually not needed each time
• But if not for TPO, there is an Authorization to
  Release form the patient must sign in order to
  release PHI
• Exceptions to having signed authorization are
  made only by a provider if ever needed
• There are Additional Restrictions for Certain
  Conditions
• Psychiatric Illness, Substance Use and HIV Status
  these require added consent to release
• A Minor May Consent for Services Related to
• Family Planning, Pregnancy, Sexually Transmitted
  Infections, Mental Health or Substance Use

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Uses and Disclosures of PHI - Review

• For TPO (Treatment, Payment and Operations) A
  general consent is signed at registration no
  need to sign each and every time we use PHI if
  used for TPO
• With Signed Authorization if not for TPO
  example Send shot records to my sons school,
  please
• Only a provider may decide to release information
  to an individual involved in the care of a
  patient without the patients authorization
  example - a patients daughter in-law gets PHI
  for a patient who has difficulty understanding

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Other Disclosures of PHI

• When Required by Law
• Child/Elder Abuse Reporting
• Court Order we must comply to a Court Order as
  written (even if without a patients consent).
  However, we often get a Subpoena for PHI. Those
  require us to contact the patient for consent, if
  one is not already included with the subpoena.
• In Cooperation with Law Enforcement
• Police may ask to search the premises in pursuit
  or in an investigation.
• The Lead Provider or CEO only may permit such
  searches

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Special Requests Patient Rights

• Patients may request
• To view their records
• Copies of their records
• To make an amendment in their Medical Record
• Special communications restrictions and notice of
  non-routine disclosures
• To file a grievance
• However, the following applies to requests
• Patients are never left un-supervised with a
  chart we give a copy or ask them to make an
  appointment to review with a provider instead
• Access can be denied if record includes
  psychotherapy notes, notes on other patients,
  records are being prepared for court preceding or
  a licensed health professional deems access would
  be detrimental to the patient
• PHS reserves the right to deny request for
  amendment. Any denial must be explained in
  writing and filed in the chart

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Special Requests (contd)

• Confidential Communication Request
• A patient may request that PHS communicate in a
  special manner, such as do not send information
  to my home address. PHS reserves the right to
  deny such requests unless patient states PHS
  communication may endanger the patient
• Example A patient in a potentially violent
  relationship may not want their partner to know
  they seek care with us, so they may ask that we
  communicate via a different address or phone
  number than their home.
• Patients may request a list of non-routine
  disclosures of information (disclosures made for
  other than TPO)
• Patient may file a grievance per policy contact
  the PHS Privacy Officer Yvette McMiller,
  Operations

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II. Abuse and Neglect

• The purpose of this section is to describe PHS
  Abuse and Neglect Policy
• You will be familiar with 3 types of abuse and
  neglect
• You will know how to respond if you witness or
  suspect abuse or neglect while at work at PHS

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PHS Abuse and Neglect Policy

• A. Child Abuse/Neglect
• Child Abuse applies to anyone under age 18
• Neglect
• Lack of proper care, supervision, or discipline
  Examples include medical neglect - a parent
  refuses to seek necessary care to maintain health
  and safety
• Abuse
• Serious, non-accidental injury or risk
• Sexual Abuse
• Sexual acts with child It is considered crime
  if the child is less than 16 the offender is
  more than 4 years older
• North Carolina Law Requires Report
• The individual witnessing reports or ensures
  reporting to Child Protective Services (CPS) of
  the Department of Social Services in the County
  where the child resides
• PHS Policy Any staff witnessing child abuse or
  neglect must report. This can be directly to CPS
  or can be discussed with the childs provider to
  help in the decision to report. Also report it
  to a clinic leader Lead Provider, RN, or Center
  Manager.

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B. Elder Abuse

• Elder Abuse applies to anyone 18 years or older
  who is not competent or independent.
• Includes
• Physical Abuse
• Sexual Abuse
• Emotional/psychological
• Neglect
• Abandonment
• Self-neglect
• Financial/material Exploitation
• National Center on Elder Abuse

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Elder Abuse (contd)

• By NC Law, anyone with reason to believe an elder
  is in need of protective services shall report
  this to the Department of Social Services of the
  county in which the elder resides
• PHS Policy Any staff member witnessing or
  suspecting abuse or neglect of a disabled adult
  should report it. Contact Adult Protective
  Services directly or discuss with the patients
  provider to make the decision to report. Also
  report to a Clinic Leader (Lead Provider, Nurse
  Manager, Center Manager)

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C. Domestic Partner Abuse

• Domestic Partner Abuse applies to any mentally
  competent and independent adult (age 18 or over)
• Domestic Partner Abuse often involves
  psychological, financial, physical and/or sexual
  abuse.
• It often includes threats regarding children
  (Youll never see your daughter again) or
  deportation (Ill call Immigration on you)
• It is serious and debilitating for all involved
• However, NC Law does not require reporting
• PHS Policy Staff suspecting Domestic Partner
  Abuse should report it to the patients Primary
  Care Provider who will decide how to discuss it
  with the patient.
• PHS providers screen and refer patients for
  further medical, counseling, law enforcement or
  shelter assistance

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III. Joint Commission on Accreditation of
Healthcare Organizations (AKA JCAHO)

• HISTORY
• In the early1900s, it was commonplace to have
  doctors visit homes to treat sick patients.
  Those who could afford the doctor visits were
  wealthy. Those who could not afford home visits
  were sent to charity hospitals, where extremely
  high percentages of patients succumbed due to
  poor environmental conditions.
• In the early 1900s, Dr. Ernest Codman, a surgeon,
  began to independently research the high
  mortality rates at hospitals and found that these
  hospitals were unsafe and unsanitary, when
  compared to homebound patient settings. Working
  with the American College of Surgeons in 1926,
  Codman helped to develop the first hospital
  standardization program and set Quality Standards
  that increased accountability for hospitals and
  patient settings.
• The first set of Joint Commission Standards
  consisted of a handbook, 18 pages in length.
  Today, the Joint Commission has evolved to be the
  most recognized accrediting body in healthcare,
  ensuring quality and safety in hospitals and
  outpatient settings.

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Joint Commission (JCAHO)

• There are 150 Standards (totaling over 300
  pages) for Ambulatory Care, alone
• April 2001 - PHS became Joint Commission
  accredited
• June 2007 Completed 3rd survey and passed,
  keeping our accreditation for another 3 years.
• PHS performs Periodic Performance Reviews
  annually
• New Employees should be ready for questions
  auditors often ask the newest to see that
  training has been effective. If you do not know
  the answer, do not guess direct the question to
  your supervisor
• Next Joint Commission Survey due in 2010
• It will be an Unannounced Survey they come at
  any time

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Joint Commission (JCAHO) cntd

• Staff have the right to contact the Joint
  Commission with any unresolved concerns about
  Quality of Care or Safety at PHS.
• If you have a concern, discuss it with your
  manager. If it cannot be resolved on the
  organizational level, then Joint Commission is a
  resource
• Mail Office of Quality Monitoring, Joint
  Commission, One Renaissance Blvd, Oakbrook
  Terrace, IL 60181 Phone [phone]
  Fax[phone] Email complaint_at_jcaho.org

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THANK YOU

• You have completed the training on HIPAA, Abuse
  and Neglect and Joint Commission.
• Please complete the HIPAA questionnaire
• Any Questions please contact
• Yvette McMiller, Operations [phone],
  mcmilley_at_piedmonthealth.org