Compliance

Salemhaven Nursing & Rehab Center

CORPORATE RESPONSIBILITY: CORE VALUES IN ACTION

We are proud to say that as a values-driven, not-for-profit, community-based healthcare organization we operate according to a set of values that are at the heart of all that we do. These values shape our commitment to those we serve, to each other, to our payers and to the government.

We have developed a program called “Organizational Integrity”  to further ensure that we continue to meet our responsibilities. An essential part of this program is “Standards of Conduct,” which, as you will note in the following statements, continues to promote our values and compliance with ethical principles, regulations and laws.

We strive to continuously shape a culture where we are known for doing the right thing for all concerned. We support and nurture our identity as a vital community-based resource.

Our effectiveness and ultimate success depends on each one of us. We thank all of our staff, directors, volunteers and associates for their continued commitment to the philosophy embraced by our founders: the provision of high-quality and compassionate healthcare.

STANDARDS OF CONDUCT

QUALITY OF CARE

We are committed to providing high-quality care and services that are focused on the persons we serve. We make every effort to render care and provide services that are both appropriate and tailored to the unique needs of each person we serve.

COMPLIANCE WITH LAWS AND REGULATIONS

We conduct our business and operations in accordance with all applicable laws, regulations and professional standards in order to maintain the integrity of our organization. Although our employees and others are not expected to be experts in law and regulation, each of us has a responsibility to understand the legal and regulatory requirements that directly affect our job.

BILLING AND CODING

We are committed to properly coding and billing the services we provide in accordance with all applicable rules and regulations established by local, state and federal authorities.

CONFLICTS OF INTEREST

We take all reasonable precautions to avoid conflicts of interest, or the appearance thereof, in the performance of our duties to our organization.  A conflict of interest exists whenever a person’s outside activities or personal interest influences or appears to influence his or her ability to make objective decisions in the course of his or her duties for the organization.

HUMAN RESOURCES

We recognize each person in accordance with our mission, value the diversity of our workforce.  Each of us shares responsibility for treating our fellow employees fairly and for maintaining a workplace that is safe and free from harassment and abuse.

ENVIRONMENT OF CARE

Maintaining a safe and effective environment of care is everyone’s responsibility. The environment of care includes such areas as general and client safety, emergency preparedness, hazardous materials and waste, fire safety, equipment management, utility management, infection control and occupational health.

SAFEGUARDING RESOURCES AND ASSETS

We share a commitment to preserve and protect our organization’s assets and the assets of others entrusted to us, including physical property and confidential information, against loss, theft or misuse.

COMMUNICATION

We encourage communication and practice an “open door” policy where information can be exchanged freely, and issues and concerns may be raised without fear of reprisal.

 

Notice Of Privacy Practices

 

SALEMHAVEN NURSING AND REHAB CENTER

23 GEREMONTY DRIVE

SALEM, NH 03079

 

 

Effective Date: 4/14/03           THIS NOTICE DESRCIBES HOW YOUR MEDICAL INFORMATION MAY BE

Revision Date:  9/01/09           USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFROMATION.

Revision Date:  9/02/13           PLEASE REVIEW IT CAREFULLY. 

 

For questions please contact:  Pamela Rutzen, Director of Social Services at 603-893-5586 extension 124.

 

 

GENERAL DESCRIPTION AND PURPOSE OF THIS NOTICE

This notice describes our medical information privacy practices including that of:

All authorized facility personnel

Any healthcare professional authorized to enter information into your medical record that is created and/or maintained by the facility

Any member of a volunteer group in our facility allowed to help you during your stay

All contracted Business Associates

All independent contractors

All officers and members of the facility’s Board of Directors

All Covenant Health Systems agents

 

All of the individuals and entities listed above will follow the terms of this notice.

These individuals or entities may share your Protected Health Information (PHI) with each other for the purposes of treatment, payment, or healthcare operations as further described in this notice.

 

OUR FACILITY POLICY REGARDING YOUR HEALTH INFORMATION

We are legally and required and committed to preserving and protecting the privacy and confidentiality of your PHI that is created and/or maintained at our facility.  This is information that could be used to identify you.  Certain state and federal laws and regulations require us to implement policies and procedures to safeguard the privacy of your health information. 

 

This notice will provide you with information regarding:

Privacy practices applicable to your PHI created and/or maintained in our facility and includes information received from other healthcare entities

Use and disclosure of your PHI and your rights and our obligations related to use and disclosure

 

We will abide by the terms of this notice including any future revisions as required or authorized by law

law.  We reserve the right to change this notice and to make the revised notice effective for any PHI already on file with us as well as PHI created and/or received in the future.  The first page of this notice contains the effective date and revision date(s).  We will post a copy of the current notice in our facility.

 

 

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USE AND DISCLOSURE OF YOUR HEALTH INFORMATION

 

DESCRIPTIVE EXAMPLES:

For Treatment- we may use your PHI to provide you with healthcare treatment and services.  We may disclose your PHI to doctors, nurses, nursing assistants, medication nursing assistants, healthcare technicians, medical, nursing students, rehabilitation specialists or other personnel involved in your healthcare.

Example: Our nursing staff may need to use your PHI in discussions with a physical therapist to coordinate services and develop a plan of care. We may also disclose your PHI to individuals or entities outside of our facility who may be involved in your healthcare such as family members, social services, or home health agencies.  (Note your right to restrict/limit defined in this document.)

 

For Payment- we may use or disclose your PHI in order to bill and collect payment from you, an insurance company, or another third party for the healthcare services you receive at our facility.

Example:  We may give information to your health plan about services you have or will receive from us in order to receive reimbursement for services provided or for prior approval for a future treatment- to assure eligibility/coverage by your health plan. We will, at your request, restrict disclosure of your PHI to any healthcare entity for any healthcare item or service which you have paid in full out of pocket.

(Note your right to restrict/limit defined in this document.)

 

For Healthcare Operations – we may use or disclose your PHI to perform functions necessary for the operation of our facility and to assure that our residents receive quality care.

Examples: We may use your PHI to review treatment and services and to evaluate staff performance in their provision of quality care to you.  We may take your photograph for medication identification purposes.  We may disclose your PHI to physicians, nurses, nursing assistants, medication nursing assistants, rehabilitative specialists and other personnel for auditing, care planning, treatment

and/or learning purposes.  We may combine collective PHI from residents in our facility for the purpose of assessment of quality of services and needs for additional services.  We may combine collective PHI from residents in our facility with collective PHI from other healthcare providers for quality assurance and improvement purposes.

When information is combined, we may remove all of your identifying information to allow for research development on the delivery of healthcare services for the purpose of continuous quality improvement.

 

ADDITIONAL USES/DISCLOSURES OF YOUR HEALTH INFORMATION

We may use/disclose your PHI through the following means and for the following purposes – other than for treatment, payment or healthcare operations as previously defined in this document as follows.

 

A. USE OR DISCLOSURE MADE PURSUANT TO YOUR VERBAL AGREEMENT

We may use or disclose certain limited PHI with your verbal agreement for purposes of:

Inclusion in our Facility Directory while you are a resident – to include name, room number, religious affiliation, and general condition description.  At your request, your religious affiliation may be given to clergy only.  Any and all other directory information may be given to people who ask for you by name.

You may opt to restrict this listing/release of the above in/from our Facility Directory. 

 

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Informing Family / Significant Others in the event of an emergency situation and you are unable to object, (because you were not present or you were incapacitated, etc.),   Disclosure may be made if it is consistent with any prior expressed wishes and determined to be in your best interest.  We will only make health information disclosure relevant to the person’s involvement in your care and/or payment for your care. 

Example: If you are sent to the emergency room, we may only inform the person that you suffered an apparent heart attack or etc. and/or we may provide information on your prognosis or progress.  You will be informed and given an opportunity to object to further disclosures as soon as you are able.

 

Notification to Family/Significant Others by disaster relief personnel/organization(s) about your condition, status, and/or location

 

B.  USE OR DISCLOSURES REQUIRING YOUR WRITTEN AGREEMENT

We may use or disclose your PHI for purposes that are not required by law only after receipt of your written authorization.  You have the right to revoke a written authorization at any time by providing us with your written revocation.  If you revoke your written authorization we will no longer use/disclose your PHI for the purposes identified in that authorization.  You understand that we are unable to retrieve any disclosures that we may have made pursuant to your authorization prior to its revocation.

Examples: Your request to provide your PHI to an attorney in a civil litigation claim or to provide your PHI for the purpose of inclusion on a mailing list.

 

C-D.  USE OR DISCLOSURE PERMITTED OR REQUIRED BY LAW

We may use or disclose your PHI without your permission when required to do so by state, federal or local law and include the following:

Public Health Activities – to those authorized by law to receive/collect PHI for the purposes of prevention/control of disease, injury or disability

Examples: Reports  of births; deaths; suspected/actual abuse, neglect or domestic violence of a child or adult; adverse reaction(s) to medication(s) or healthcare product(s); notice of product recalls (to individuals); disease/exposure risk (to individuals)

 

Health Oversight Activities – to those authorized by law to monitor persons/organizations providing healthcare to individuals in order to assure compliance

Examples: Licensure/Certification Surveys; audits; investigations; or inspections

 

Judicial or Administrative Proceedings – to courts and administrative agencies with legal authority to hear and resolve lawsuits or disputes – only after we have made an effort to notify you about the request or obtain an order protecting your PHI – prior to the use/disclosure of your PHI

Examples: Pursuant to a Court Order; Subpoena; Discovery Request; or any other lawful process issued by a judge or others involved in a dispute

 

Law Enforcement Officials – for the purpose of responding to:

Examples: Court Order; Subpoena; Warrant; Summons; or similar lawful process; identification or location of a suspect; fugitive; material witness; missing person; or crime victim

 

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Reporting of a death due to possible criminal conduct; criminal conduct within our facility

Emergency/Criminal Activity – crime location(s); potential victim(s)

Identity; location; description of suspect

 

Coroners, Medical Examiners or Funeral Directors – for legal process at time of death

Examples: Identification of the deceased; determination of cause of death

 

Serious Threat to Health or Safety – to individuals/organizations that have the authority/ability to assist in prevention of the realization of a threat to you or others

 

Military Personnel/Veterans – PHI of domestic or foreign armed forces as required by the appropriate military command authorities

 

National Security and Intelligence Activities – to authorized federal officials

Examples: intelligence; counterintelligence; and/or for other national security activities

 

Protective Services for the President and Others – to authorized federal officials for the purpose of providing protection or conducting special investigations to the President, other authorized persons or foreign heads of state

 

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You or your DPOA-HC if activated, or your Legal Guardian has the following rights regarding your PHI that we create or maintain:

To inspect and copy – PHI that may be used to make decisions about your healthcare which includes medical and billing records but not psychotherapy notes

A written request to inspect and copy your PHI, including PHI held electronically, must be submitted to:

Linda Cooper, Medical Records Coordinator

We may charge a fee for costs of copying, mailing, and/or other related items or we may deny your request in certain limited instances.  If your written request is denied you may request a review of the denial. The licensed professional at the facility conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

 

To request an amendment - of PHI that you believe to be incomplete and/or inaccurate, a written request, (including supporting reasons), to amend must be submitted to:

Pamela Rutzen, Director of Social Services

 

We may deny your PHI amendment request for the following reasons.

Your request was:     Not in writing;

                                      Does not include supporting reasons;

Your requested PHI: Was not created by us (unless the person or entity that created the information is             

                                      no longer available to make the amendment);

                                      Is not part of the PHI kept by or for our facility;

                                      Is not part of the PHI allowed by law to be inspected and/or copied;

                                      Is accurate and complete     

 

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To an Accounting of Disclosures – a written request for an accounting of your PHI disclosures must be submitted to:  Linda Cooper, Medical Records Coordinator

Your dated request must state a time period no longer than six (6) years prior or before April 14, 2003 and indicate in what form you wish to receive the accounting:  paper, electronic, etc.

 

The accounting of disclosures of your PHI does not include disclosures made for purposes of treatment, payment, healthcare operations, any disclosures you authorized or other disclosures for which an accounting is not required under HIPAA.

 

We will respond to your request within sixty (60) days of the receipt of your written request.

You will be notified if additional time is needed to reply, however, in no case will such extension exceed thirty (30) days.

The first accounting will be at no charge.  Subsequent accountings within a twelve (12) month period will include a charge.  The facility will provide notice of the final cost prior to the accounting in order to allow for the withdrawal or modification of your request before any costs are incurred.

 

To Request Restrictions – or limitations on your PHI that is used or disclosed for treatment, payment or healthcare operations or to a family member/significant other routinely involved in your care or payment for your care.  

Example: information regarding a specific treatment received or planned

A written request must be submitted to: Pamela Rutzen, Director of Social Services

And must include:  specific PHI to limit; specific limits on use, disclosure or both; specific person(s) to whom limits apply. We are not required to agree/comply with your request in the event that the use and/or disclosure of specific PHI is necessary for the provision of emergency treatment to you.

 

Use/Disclosure of Genetic Information - The Genetic Information Nondiscrimination Act, (GINA), prohibits the use and/or disclosure of genetic information for underwriting purposes.

 

To Request Confidential Communications – about your healthcare through specific means and/or at a specific location(s), a written request must be submitted to:  Pamela Rutzen, Director of Social Services

and must specify:  how you wish to be contacted and where you wish to be contacted.  We will not ask the reason for your request and will accommodate all reasonable requests.

Example:  You wish to be contacted at your place of employment only or by mail only.

 

Activities Requiring Patient Authorization - for the disclosure of PHI for marketing or fundraising

activities. 

 

Disclosure of PHI of the Deceased - if an individual has been deceased for fifty (50) years or more, PHI is not covered by HIPAA.  Disclosures are permitted to family members and others who were involved in the care or payment for the care if not contrary to prior expressed preference.

 

 

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To Breach Notification – If it is determined by an investigation that unsecured PHI was inappropriately disclosed and a breach of your information occurred, you will receive notification of the breach by first class mail.

 

To a Paper Copy of This Notice – You may ask for a paper copy of this notice at any time, even if you have previously agreed to receive this notice electronically.  To obtain a paper copy of this notice, contact:  Linda Cooper, Medical Records Coordinator at 603-893-5586, extension 106

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All written requests should be submitted to the respective facility personnel identified in this notice at:

Salemhaven

23 Geremonty Drive

Salem, NH 03079

 

COMPLAINTS -  If you believe your privacy rights have been violated, you may file a written complaint

with:  Raymond Milliard, Administrator at the above address or email rmilliard@salemhaven.com

 

or with the Secretary of the Department of Health and Human Services (HHS) at:

200 Independence Avenue, S.W., Washington, D.C. 20201,  (202) 619-0257 or toll-free 1-877-666-6775