Policy: A2Z Home Health Care LLC shall observe privacy practices with respect to individually identifiable health information. These practices are designed to protect the privacy, use and disclosure of protected health information in accordance with the federal requirements of the Health Information Portability and Accountability Act (HIPAA) regulations.

A2Z Home Health Care may not use or disclose protected health information, except either: (1) as the Privacy Rule permits or requires; or (2) as the individual who is the subject of the information (or the individual’s personal representative) authorizes in writing.

Required Disclosures: The agency must disclose protected health information in only two situations: (a) to individuals (or their personal representatives) specifically when they request access to, or an accounting of disclosures of, their protected health information; and (b) to Department of Health and Human Services when it is undertaking a compliance investigation or review or enforcement action.

Purpose: To accommodate client privacy rights as specified in the privacy rule of the Health Information Portability and Accountability Act (HIPAA) regulation. To inform the agency’s clients of their rights of privacy.

Process:

1. All clients at the time of admission receive information about the PHI (Protected Health Information) privacy practices of A2Z Home Health Care LLC.
2. Use and disclosure of PHI shall occur only with respect to the staff of A2Z Home Health Care LLC who have an essential need for the PHI in order to carry out their job tasks and responsibilities. Such employees shall not use or disclose PHI to other employees. The importance of PHI privacy practices is inserted into the Employee Handbook.
3. The PHI privacy practices are reviewed with all new employees during the agency orientation, and with all current employees annually. Any violation by an employee of a patient’s privacy shall be grounds for disciplinary action, including termination of employment.
4. A2Z Home Health Care LLC shall observe the following steps to ensure client PHI security at the office
5. All information maintained in computer records will be password protected and only authorized personnel will have access.
6. All staff that have passwords to access the Agency and client information will keep the password protected and not allow others to know the password or use it.
7. Client information will not be visible on computer monitors when not in use.
8. The agency shall maintain all client records and files confidentially and kept in a secure place with limited access.
9. Any use and disclosure of PHI that is subject to the HIPAA accounting requirement shall be maintained in an appropriate database, electronic or written, with performance of routine backing up, and shall be maintained for at least six years from the date of the use and disclosure.
10. All contracts with business associates shall include the HIPAA required “satisfactory assurances” and shall be maintained in a readily retrievable manner.

CLIENT RESTRICTION REQUEST

Policy: Clients or their representatives have the right to request restriction on how their protected health information (PHI) is used and/or disclosed.

Purpose: A2Z Home Health Care LLC will identify steps to assure compliance with client request for restrictions without compromising agency’s ability to provide appropriate care and treatment.

Process: 

1. Clients and their representatives are informed of their right to request restrictions on the use and disclosure of their protected health information.
2. Clients are requested to provide their consent in writing by signing the Consent to Use and Disclose Health information forms.
3. Client’s requests for restriction on the use and disclosure of this information will be forwarded in writing to the agency for approval.
4. Agency will agree to the client request for restrictions on the use and disclosure of their health information if it is reasonable and deemed to be in the client’s best interest.

When a request for restrictions is accepted – The client is informed of any potential consequences of the restriction and the restriction is noted in the clinical record. The Agency staff are instructed to comply with the agreed upon restriction.

Client is informed that the agency is not required to comply with restrictions in an emergency situation.

When a request for restriction may be denied – The client will be provided with an explanation of the reasons for the denial and the client shall be given the opportunity to discuss his/her privacy concerns.

Efforts shall be made to assist the client in modifying the request for restrictions to accommodate their concerns and obtain agreement by the Agency.

 

ADDITIONAL CLIENT PHI RIGHTS

1. To request to receive confidential communication
2. To access their protected health information for inspection or copying
3. To amend their health care information and
4. To request for accounting.

Process: Any client requesting the exercising of any of the above-listed rights shall be requested to complete the form that relates to the client right. However, if a client refuses to complete the form, and instead wants to exercise the right based only upon an oral request, the staff on duty shall make a good faith effort to accommodate the client request.

 

Content: An accurate and complete client record shall be maintained for each client receiving services and shall include, but shall not be limited to:

1. Admitting information, including client history:

The Intake Forms shall include:

1. Client’s information: name, social security number, date of birth, gender, current address, telephone number, responsible party information, if any and their Medicaid number
2. Referral source, date of discharge from a facility, as applicable
3. Name, address, and telephone number of nearest relative or responsible person to contact in the event of an emergency
4. Primary care physician information: Name, address, and contact information
5. Diagnosis: principle and secondary
6. All pertinent medical information necessary to provide care including any treatment plan if applicable and any known allergies
7. Names of other individuals/organizations who might be involved in care
8. Information on the composition of the client’s household, including individuals to be instructed in assisting the client;
9. An initial assessment of the client needs to develop a plan of care or services:

For Medicaid patients DMAS-99 (Community-Based Care Recipient Assessment Report) or other DMAS advised form shall be used.

4. A plan of care for service that includes the type and frequency of each service to be delivered either by organization personnel or contract services;

A Plan of Care shall be developed with all clients upon admission, before care is provided. The plan will identify the services to be provided, disciplines providing care, charges and expected sources of reimbursement for services, payers and supervisory responsibilities. The client will be informed of their liability for payment.

The Plan of Care shall be developed in an easily understood format and terms that identify the duties to be performed within the state guidelines

      The number of days the client is visited will be determined by:

1. Physician’s orders/medical necessity
2. Client’s cognitive status
3. Client’s self-care ability
4. Assistance available in the home
5. Rehabilitation objectives
6. Client safety

5. Documentation of client rights review

A signed copy of client’s rights after patient has read, understood and discussed shall be kept in their clinical record file.

8. A discharge or termination of service summary along the following lines;
   1. Patient status at the time of admission to the agency.
   2. Status at discharge/last current visit and continuing care needs.
   3. Name of person or organization assuming responsibility for care.
   4. Reason for discharge, if applicable, and date of discharge.

 

Aides Record: Signed and dated notes on the care or services provided by each individual delivering service shall be written on the day the service is delivered and incorporated in the client record within seven working days. Following steps shall be observed in this regard:

Caregivers shall document care/services provided in accordance with the Plan of Care designed for the patient so that there is a record of the care performed on each visit.

The caregiver shall utilize the appropriate service record form to document services rendered to the client.

The caregiver shall be responsible for reporting any changes in the client’s condition or other pertinent observations to the Registered Nurse or report it to the agency office.

The Registered Nurse shall be responsible for reviewing the service record before it is placed in the chart.

Record of care or service provided by aide or RN shall have prominent areas for input of dates and signatures for

1. Date service provided and notes annotated
2. Date service reviewed and filed within client record

The importance of completion of the above within seven (7) working days will be part of

1. Guidelines provided to the individual regarding timeliness of job completion
2. Performance evaluation checklist to accentuate the importance of recording notes of services provided to the client

At completion of care, the clinical record will be audited within one month to ensure all necessary medical records are present and completed. All extra copies of clinical record data will be destroyed.