HIPAA/Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
We have summarized our responsibilities and your rights on this first page. For a complete description of our privacy practices, please review this entire notice.
Our nursing facility is required to:
- Maintain the privacy of your health information
- Provide you with this notice of our legal duties and privacy practices with respect to information we collect and maintain about you
- Abide by the terms of this notice
As a resident of our nursing facility, you have several rights with regard to your health information, including the following:
- The right to request that we not use or disclose your health information in certain ways.
- The right to request to receive communications in an alternative manner or location.
- The right to access and obtain a copy of your health information.
- The right to request an amendment to your health information.
- The right to an accounting of disclosures of your health information.
We reserve the right to change our privacy practices and to make the new provisions effective for all health information we maintain. Should our privacy practices change, we will post the changes on the bulletin board in our facility, as well as, on our web site. A copy of the revised notice will be available after the effective date of the changes upon request.
We will not use or disclose your health information without your authorization, except as described in this notice.
If you have questions and would like additional information, you may contact our facility's Privacy Officer: Vicky Chambers at 419-861-4907 (2021 N. McCord Road, Toledo, Ohio 43615.)
Understanding Your Health Record/Information
Each time you visit a nursing facility, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
- Basis for planning your care and treatment
- Means of communication among the many health professionals who contribute to your care
- A tool with which we can assess and continually work to improve the care and services we render and the outcomes we achieve
- Legal document describing the care you received
- Means by which you or a third-party payer can verify that services billed were actually provided
- A tool in educating health professionals
- A source of data for medical research
- A source of information for public health officials who oversee the delivery of health care in the United States
- A source of data for facility planning and marketing
Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
How We Will Use or Disclose Your Health Information
We will use or disclose your health information for treatment purposes, including for the treatment activities of other health care providers. For example, information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you're discharged from our nursing facility.
We will use or disclose your health information for payment, including for the payment activities of other health care providers or payers. For example, a bill may be sent to you or a third-party payer, including Medicare or Medicaid. The information on or accompanying the bill may include information that identifies you, as well as your diagnoses, procedures, and supplies used in providing your care.
Health Care Operations
We will use or disclose your health information for our regular health operations. For example, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.
In addition, we will disclose your health information for certain health care operations of other entities. However, we will only disclose your information under the following conditions: (a) the other entity must have, or have had in the past, a relationship with you; (b) the health information used or disclosed must relate to that other entity's relationship with you; and (c) the disclosure must only be for one of the following purposes: (i) quality assessment and improvement activities; (ii) population-based activities relating to improving health or reducing health care costs; (iii) case management and care coordination; (iv) conducting training programs; (v) accreditation, certification, licensing, or credentialing activities; or (vi) health care fraud and abuse detection or compliance.
There are some services provided in our organization through the use of outside people and entities. Examples of these “business associates” include our accountants, consultants and attorneys. We may disclose your health information to our business associates so that they can perform the job we've asked them to do. To protect your health information, however, we require the business associates will appropriately safeguard your information.
Unless you notify us that you object, we may use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. We may also use your name on a nameplate next to or on your door in order to identify your room, unless you notify us that you object.
We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition and significant change in your condition. If we are unable to reach your family member of personal representative, then we may leave a message for them at the phone number that they have provided use, e.g., on an answering machine.
Communication with Family
We may disclose to a family member, other relative, close personal friend or any other person involved in your health care, health information relevant to that person's involvement in your care or payment related to your care.
We may disclose information to researchers when certain conditions have been met.
Transfer of Information at Death
We may disclose health information to funeral directors, medical examiners, and coroners to carry out their duties consistent with applicable law.
Organ Procurement Organizations
Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
We may contact you regarding your treatment, to coordinate your care, or to direct or recommend alternative treatments, therapies, health care providers or settings. In addition, we may contact you to describe a health-related product or service that may be of interest to you, and the payment for such product or service.
We may contact you as part of a fund-raising effort.
Food and Drug Administration (FDA)
We may disclose to the FDA, or to a person or entity subject to the jurisdiction of the FDA, health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to Workers' Compensation or other similar programs established by law.
Occupational Safety and Health Administration (OSHA)
We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to OSHA or other similar programs established by law.
As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling infectious diseases, injury, or disability.
Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member of business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more residents, workers or community members.
Your Health Information Rights
Although your health record is the physical property of the nursing facility, the information in your health record belongs to you. You have the following rights:
- You may request that we not use or disclose your health information for a particular reason related to treatment, payment, the facility's general health care operations, and/or to a particular family member, other relative or close personal friend. We ask that such requests be made in writing on a form provided by our facility. Although we will consider your requests with regard to the use of your health information, please be aware that we are under no obligation to accept it or to abide by it. We will abide by your requests with regard to the disclosure of your clinical and personal records to anyone outside of the facility, except in an emergency, if you are being transferred to another health care institution, or the disclosure is required by law. 42 Code of Federal Regulations (C.F.R.) 483.10(e) provides that a NF must abide by a resident's right to refuse the release of his/her personal or clinical records to any individual outside of the facility, unless the release is necessary because the resident is being transferred to another health care institution, or it is required by law.
- If you are dissatisfied with the manner in which or the location where you are receiving communications from us that are related to your health information, you may request that we provide you with such information by alternative means or at alternative locations. Such a request must be made in writing and submitted to the Privacy Officer: Vicky Chambers, 419-861-4907, at 2021 N. McCord Road, Toledo, Ohio 43615. We will attempt to accommodate all reasonable requests. For more information about this right, see 45 C.F.R. 164.522(b), which is located in the executive director's office.
- You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by law. You may make such requests orally or in writing; however, in order to better respond to your request we ask that you make such requests in writing on our facility's standard form. If you request to have copies made, we will charge you a reasonable fee. For more information about this right, see 45 C.F.R. 164.524, which is located in the executive director's office.
- If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing, and must provide a reason to support the amendment. We ask that you use the form provided by our facility to make such requests. For a request form please contact the Privacy Officer. For more information about this right, see 45 C.F.R. 164.526, which is located in the executive director's office.
- You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request, up to a maximum of 6 years. We ask that such requests be made in writing on a form provided by our facility. Please note that an accounting will not apply to any of the following types of disclosures: disclosures made for reasons of treatment, payment or health care operations; disclosures made to you or your legal representative, or any other individual involved with your care; disclosures to correctional institutions or law enforcement officials, and disclosures for national security purposes. You will not be charged for your first accounting request in any 12 month period. However, for any requests that you make thereafter, your will be charged a reasonable, cost-based fee. For more information about this right, see 45 C.F.R. 164.528, which is located in the executive director's office.
- You have the right to obtain a paper copy of our Notice of Privacy Practices upon request. You may also access and print a copy of our notice from our website: www.lutheranhomessociety.org.
- You may revoke an authorization to use or disclose health information, except to the extent that action has already been taken. Such a request must be made in writing and directed to the Privacy Officer: Vicky Chambers, 419-861-4907, at 2021 N. McCord Road, Toledo, Ohio 43615.
For More Information or to Report a Problem
If you have questions and would like additional information, you may contact our facility's Privacy Officer: Vicky Chambers at 419-861-4907 (2021 N. McCord Road, Toledo, Ohio 43615.)
If you believe that your privacy rights have been violated, you may file a complaint with us. These complaints must be filed in writing on a form provided by our facility. The complaint form may be obtained from the Privacy officer and, when completed, returned to the Privacy Officer: Vicky Chambers, 419-861-4907, at 2021 N. McCord Road, Toledo, Ohio 43615. You may also file a complaint with the Secretary of the federal Department of Health and Human Services. There will be no retaliation for filing a complaint.
Effective Date: April 14, 2003
HIPAA/Notice of Privacy Practices Dissemination
It is the policy of Lutheran Homes Society to disseminate a written notice to all residents that addresses its policies and procedures with respect to the treatment, use and disclosure of individually identifiable health information and with respect to our facilities' legal duties with respect to such information (a “Notice of Privacy Practices”).
The Notice of Privacy Practices shall include all elements and statements that are required by law. In summary, the Notice shall inform the residents about the potential uses and disclosures of their health information, as well as their rights with respect to that information, including: (1) a description of each of the purposes for which the Facility is permitted to disclose their health information, including, for example, treatment, payment, and health care operations; and (2) a description of when written authorization is required before the Facility may disclose the individual's health information in other instances.
- Facility will provide the Notice of Privacy Practices at the time of admission or when service is first provided to the individual, whichever is first, and obtain written acknowledgment of receipt of the notice.
- A copy of the Notice of Privacy Practices will be kept in the resident's medical record, or the Notice's form number or effective date will be recorded.
- Facility will provide a copy of the Notice of Privacy Practices to residents and to any other person upon request.
- Facility will post a copy of the Notice of Privacy Practices on its bulletin board in the entrance lobby, and on its website: www.LutheranHomesSociety.org.
- If there is a material change in the Facility's use and disclosure policy that affects the rights of residents, legal duties imposed, or the practices of the Facility, then a new Notice of Privacy Practices will be posted on the Facility's bulletin board and on its web site. Material changes will not be implemented until a revised notice has been posted by the Facility. Updated Notices will not be provided to residents, but will be made available upon request.
- The Facility's Privacy Officer shall be responsible for ensuring that written notices are received and posted in accordance with this policy, and for keeping copies of the notices posted and any revisions thereto.
Employee Internet Policy
LHS's computing and telecommunicating networks, computing equipment and computing resources are owned by LHS and are provided primarily to support the company's business and administrative needs. Federal and state law and LHS's own Policies and Procedures, govern the usage of equipment and technology. This Policy establishes rules governing employee use of LHS-provided Internet services. The Internet is a powerful communications tool and a valuable source of information about vendors, customers, competitors, technology, and new products and services. However, an employee's improper use of LHS-provided Internet services can waste time and resources and create legal liability and embarrassment for both LHS and the employee.
An Internet service includes, but is not limited to: e-mail, FTP, telnet, web browsing, and Usenet or newsgroups. This policy applies to any Internet service that is:
- Accessed on or from LHS's premises;
- Accessed using company computer equipment or via company-paid access methods; and/or
- Used in a manner that identifies the individual with the company.
Except as set forth in the next paragraph, employees are strictly prohibited from using LHS-provided Internet services in connection with any of the following activities:
- Engaging in illegal, fraudulent, or malicious conduct;
- Working on behalf of organizations without any professional or business affiliation with LHS;
- Sending, receiving, or storing offensive, obscene, or defamatory material;
- Harassing other individuals;
- Sending uninvited e-mail of a personal nature;
- Monitoring or intercepting the files or electronic communications of employees or third parties;
- Obtaining unauthorized access to any computer system, files or data, regardless of whether the system, files or data are securely protected;
- Using another individual's account or identity;
- Attempting to test, circumvent, or defeat security or auditing systems of LHS or any other organization without prior authorization; or
- Distributing or storing chain letters, jokes, solicitations, offers to buy or sell goods, or other nonbusiness material of a trivial or frivolous nature.
- Releasing a virus, worm or other program that damages or otherwise harms a system or network;
- Sending a crippling number of files across the network, which would cause the system to slow or crash (e.g. email "bombing");
- Tapping phone or network lines (e.g. running network sniffers without authorization)
Internet services are provided by LHS for employees' business use. Very limited or incidental use of Internet services for personal, nonbusiness purposes is acceptable. However, personal use must be infrequent and must not:
- Involve any prohibited activity (see above);
- Interfere with the productivity of the employee or his or her co-workers;
- Consume system resources or storage capacity on an ongoing basis; or
- Involve large file transfers or otherwise deplete system resources available for business purposes.
LHS Monitoring Rights
Employees should not expect privacy with respect to any of their activities using LHS-provided Internet access or services. LHS reserves the right to review any files, messages, or communications sent, received, or stored on LHS's computer systems.
“Confidential information” or “trade secrets” includes any confidential or proprietary knowledge or information no matter when or how acquired, concerning the conduct and detail of LHS's business including, but not limited to, information concerning marketing methods, pricing information, research, sales and technical data, manufacturing methods and techniques, products, know-how or information concerning the needs and requirements of LHS's customers, clients and accounts.
All employees are expected and required to protect LHS's trade secrets and other confidential information. Company trade secrets or confidential information should never be transmitted or forwarded to outside individuals or companies not authorized to receive the information. Employees must exercise greater care when transmitting LHS trade secrets using the internet, e-mail or other electronic forms of communication that with other communication means because electronic means make it easier to redistribute or misdirect trade secrets to unauthorized individuals.
LHS also requires its employees to use the Internet in a way that respects the confidential and proprietary information of others. Employees are prohibited from copying or distributing copyrighted or proprietary materials of others-for example, software, digital audio files, database files, documentation, or articles-using the internet or other electronic forms of communication.
The Internet is an inappropriate method of communicating certain types of confidential information. Employees should consult their supervisor and the systems administrator before posting or transmitting sensitive or confidential information.
Employees violating this policy are subject to discipline, up to and including termination of employment. Employees using LHS's computer system for defamatory, illegal, or fraudulent purposes and employees who break into unauthorized areas of LHS's computer system also are subject to civil liability and criminal prosecution.
Approved by LHS Board 4/10/08.