LAKEWOOD COMMUNITY SERVICES CORPORATION

POLICY AND PROCEDURES MANUAL

Policy No. OP-12

Confidentiality

1. Purpose

LCSC is committed to ensure the privacy of consumer interactions and documentation as delineated in N.J.A.C. 10:37-6.79 and to remain compliant with the Health Insurance Portability and Accountability Act 45 CFR Parts 160 and 164 and 42 CFR Part 2.  Disclosure of protected health information is legally allowed in certain circumstances, such as in emergency situations and during audits by funding and licensing agencies.  

2. Policy

It is the policy of LCSC to remain compliant with the Health Insurance Portability and Accountability Act HIPAA, (Pub. L. No. 104- 191, 110 Stat. 1936 (1996)),  Parts 160 and 164 and 42 CFR Part 2.  Disclosure of protected health information (PHI) is legally allowed in certain circumstances, such as in emergency situations and during audits by funding and licensing agencies.  LCSC is committed to obtain appropriate consents when exchange of PHI would benefit treatment.  LCSC uses Adaptamed’s EhrYourWay, LCSC’s health information technology system, is certified to send and receive the full common data set for all summary of care records; to support capabilities including transitions of care, privacy, and security; and to meet the Patient Creation list criterion (45 CFR 170.314(a)(14)) established by the office of National coordinator (ONC) for ONC Health IT Certification Program.

3. Discussion

All staff will be trained in requesting written consumer consents when PHI (protected health information) is to be obtained or released.  A written consumer consent from a known community provider or agency can be used in lieu of an LCSC consent for the disclosure of information to that provider (This consent will be uploaded in the document section of the electronic health record).  The release of PHI without an appropriate consent is reason for disciplinary action, including termination from employment.  Adult consumers can give authorization for disclosure of confidential health information.  Consumers under the age of 18 need an authorization for the disclosure of confidential health information to be signed by a parent or legal guardian. The LCSC Authorization to obtain/disclose health information contains:

• The name of the consumer

• The name or the title of the person or organization/agency/school to which LCSC can release information.

• The name or the title of the person or organization/agency/school from which LCSC can obtain information.

• The purpose of the disclosure 

• The information to be disclosed

• The date on which the authorization is completed.

• The written signature or verbal consent of the consumer or of a person authorized by law to sign or give verbal consent for the consumer, following a statement that the undersigned understands the nature of the authorization and has been informed that he or she has the right to revoke consent at any time by written communication to the LCSC Outpatient director Executive Administration.

• LCSC’s authorizations to obtain/disclose health information expire automatically at discharge, at the date written on the form, or when revoked in writing at any time.

Consumer records may be disclosed without written consent pursuant to a court order directing disclosure.   LCSC staff have access to consumer records for the purposes of consumer care, maintaining clinical files, billing, and case discussions.  Violation of the policy can lead to termination.

Clinical records may be disclosed to authorized audit teams, monitoring and site review staff designated by the Department of Legislative Services, The New Jersey Department of Health and senior services, the Division of Mental Health and Addictions Services, and the Center for Medicaid and Medicare services.  The State Medical Examiner or a County medical examiner may access clinical information for investigations.

The records of a minor shall be released upon request to the Department of Children and Families in connection with investigations of whether the minor has been abused or neglected.  

All members attending family therapy sessions need to consent to the release of information.

Consumers are entitled to inspect and/or receive a copy of his/her clinical record unless the consumer’s treating clinician certifies to the agency that such disclosure would be seriously harmful to the consumer’s treatment or health.  LCSC staff is encouraged to explain reasons to the consumer for denial of access and the reason(s) in the file.

A consumer may submit a modification of his/her clinical record to be included in the consumer’s file. LCSC will cooperate with the consumer in amending his/her clinical record upon request within 10 days of receipt of request.

Consumers are offered the Notice of Privacy during the first clinic visit and educated about the need for consents, confidentiality, and the grievance procedure during the first clinic visit and as requested.

Consumers are entitled to see their financial record with LCSC.

 LCSC encourages case presentations to be done with first or changed names for training and group supervision purposes. Individual supervision is conducted with the name of the person served.

Information may be disclosed to a licensed mental health provider or medical health care provider who has a contract with DMHAS or DHS, or to the consumer’s personal physician if it appears that the information is to be used for the benefit of the consumer and consent is obtained.

 LCSC encourages each consumer to sign a consent to disclose/obtain information from the consumer’s primary care physician to better integrate somatic and mental health for the consumer’s benefit. 

LCSC will cooperate with the release of records to an interested party described in 10:37-6.79(g) of a deceased consumer when there is proper written notice and the information is deemed relevant.  LCSC keeps the records of consumers for six years and will cooperate with all reasonable requests and legal requests during that time. LCSC can list information obtained from other agencies, but cannot disclose this information.  Consumers or interested parties will need to contact the outside agencies separately.

All computer systems which store consumer data are password protected and computer screens with consumer data will be kept out of sight from consumers. The topic of Cyber Security has been added to LCSC’s annual training to help staff recognize suspicious emails.

Consumer data which needs to be faxed or transmitted is only done for the benefit or at the request of the consumer.  It is accompanied by a cover fax sheet if it is unknown if the fax machine is in an unprotected area for receiving PHI or if the data is addressed to a particular person in a work area.  

LCSC email systems are HIPAA compliant, but LCSC assumes the email used by LCSC consumers and families do not have that level of protection.  Therefore, LCSC does not allow sharing of clinical information with consumers via email.  LCSC does not allow ANY communication with or about consumers and families via social media.  Staff is trained that sharing PHI via social media is a cause for dismissal.  LCSC allows communication via text for the purpose of scheduling and canceling appointments only.  Cell phone usage is permitted for scheduling and canceling appointments and for brief questions regarding treatment if appropriate or to call regarding non-life threatening emergencies.

In the electronic health record, only those users who are linked to a person receiving services will have access to that particular person’s files.  The administrative staff has access to all the records, but under no condition will this access be abused.  Abuse of the privilege of access to the records can lead to dismissal and/or other repercussions.  

At no time will any staff member discuss the content of any consumer with anyone outside of the agency for any purpose other than that directly related to consumer care if legally allowable.  Consumer information used for outside training purposes will be disguised.  A staff member can face immediate termination for violation of this policy.  For the benefit of LCSC consumers and families a Code of Ethics adapted from the (National Association of Social Workers) NASW Code of Ethics is posted to remind LCSC consumers and families that LCSC values the trust consumers have in LCSC’s program and LCSC does not take that trust for granted.  The Code of Ethics states:

ETHICAL RESPONSIBILITIES TO PEOPLE WHO COME FOR SERVICES PROVIDED BY LCSC CLINICIANS

1.  Commitment to Consumers

Clinicians’ primary responsibility is to promote the well-being of consumers. In general, consumers’ interests are primary. However, social workers’ responsibility to the larger society or specific legal obligations may on limited occasions supersede the loyalty owed clients, and clients should be so advised. 

2. Self-Determination

Clinicians respect and promote the right of consumer to self-determination and assist consumers in their efforts to identify and clarify their goals. Clinicians may limit consumers’ right to self-determination when, in the social workers’ professional judgment, consumers’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.

3. Informed Consent

(a) Clinicians should provide services to consumers only in the context of a professional relationship based, when appropriate, on valid informed consent. Clinicians should use clear and understandable language to inform consumers of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients’ right to refuse or withdraw consent, and the time frame covered by the consent. Clinicians should provide clients with an opportunity to ask questions.

(b) In instances when consumers are not literate or have difficulty understanding the primary language used in the practice setting, clinicians should take steps to ensure consumers’ comprehension. This may include providing consumers with a detailed verbal explanation or arranging for a qualified interpreter or translator whenever possible.

(c) In instances when consumers lack the capacity to provide informed consent, social workers should protect consumers’ interests by seeking permission from an appropriate third party, informing consumers consistent with the consumers’ level of understanding. In such instances clinicians should seek to ensure that the third party acts in a manner consistent with consumers’ wishes and interests. Clinicians should take reasonable steps to enhance such consumers’ ability to give informed consent.

4. Competence

(a) Clinicians should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.

(b) Clinicians should provide services in substantive areas or use intervention techniques or approaches that are new to them only after engaging in appropriate study, training, consultation, and supervision from people who are competent in those interventions or techniques.

(c) When generally recognized standards do not exist with respect to an emerging area of practice, clinicians should exercise careful judgment and take responsible steps (including appropriate education, research, training, consultation, and supervision) to ensure the competence of their work and to protect clients from harm.

5. Cultural Competence and Social Diversity

(a) Clinicians should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.

(b) Clinicians should have a knowledge base of their consumers’ cultures and be able to demonstrate competence in the provision of services that are sensitive to consumers’ cultures and to differences among people and cultural groups.

(c) Clinicians should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability.

6. Conflicts of Interest

(a) Clinicians should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Clinicians should inform consumers when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the consumers’ interests primary and protects consumers’ interests to the greatest extent possible. In some cases, protecting consumers’ interests may require termination of the professional relationship with proper referral of the consumer.

(b) Clinicians should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.

(c) Clinicians should not engage in dual or multiple relationships with consumers or former consumers in which there is a risk of exploitation or potential harm to the consumer. In instances when dual or multiple relationships are unavoidable, clinicians should take steps to protect consumers and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when clinicians relate to consumers in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)

(d) When clinicians provide services to two or more people who have a relationship with each other (for example, couples, family members), clinicians should clarify with all parties which individuals will be considered consumers and the nature of clinicians’ professional obligations to the various individuals who are receiving services. Clinicians who anticipate a conflict of interest among the individuals receiving services or who anticipate having to perform in potentially conflicting roles (for example, when a clinician is asked to testify in a child custody dispute or divorce proceedings involving consumers) should clarify their role with the parties involved and take appropriate action to minimize any conflict of interest.

7.  Privacy and Confidentiality

(a) Clinician should respect consumers’ right to privacy. Clinicians should not solicit private information from consumers unless it is essential to providing services or conducting social work evaluation or research. Once private information is shared, standards of confidentiality apply.

(b) Clinicians may disclose confidential information when appropriate with valid consent from a consumer or a person legally authorized to consent on behalf of a consumer.

(c) Clinicians should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons. The general expectation that clinicians will keep information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and imminent harm to a consumer or other identifiable person. In all instances, clinicians should disclose the least amount of confidential information necessary to achieve the desired purpose; only information that is directly relevant to the purpose for which the disclosure is made should be revealed.

(d) Clinicians should inform clients, to the extent possible, about the disclosure of confidential information and the potential consequences, when feasible before the disclosure is made. This applies whether clinicians disclose confidential information on the basis of a legal requirement or consumer consent.

(e) Clinicians should discuss with consumers and other interested parties the nature of confidentiality and limitations of consumers’ right to confidentiality. Clinicians should review with consumers’ circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. This discussion should occur as soon as possible in the clinician-consumer relationship and as needed throughout the course of the relationship.

(f) When clinicians provide counseling services to families, couples, or groups, clinicians should seek agreement among the parties involved concerning each individual’s right to confidentiality and obligation to preserve the confidentiality of information shared by others. Clinicians should inform participants in family, couples, or group counseling that clinicians cannot guarantee that all participants will honor such agreements.

(g) Clinicians should inform consumers involved in family, couples, marital, or group counseling of the clinician’s, employer’s, and agency’s policy concerning the clinician’s disclosure of confidential information among the parties involved in the counseling.

(h) Clinicians should not disclose confidential information to third-party payers unless clients have authorized such disclosure.

(i) Clinicians should not discuss confidential information in any setting unless privacy can be ensured. Clinicians should not discuss confidential information in public or semipublic areas such as hallways, waiting rooms, elevators, and restaurants.

(j) Clinicians should protect the confidentiality of consumers during legal proceedings to the extent permitted by law. When a court of law or other legally authorized body orders clinicians to disclose confidential or privileged information without a consumer’s consent and such disclosure could cause harm to the consumer, clinicians should request that the court withdraw the order or limit the order as narrowly as possible or maintain the records under seal, unavailable for public inspection.

(k) Clinicians should protect the confidentiality of consumers when responding to requests from members of the media.

(l) Clinicians should protect the confidentiality of consumers’ written and electronic records and other sensitive information. Clinicians should take reasonable steps to ensure that consumers’ records are stored in a secure location and that consumers’ records are not available to others who are not authorized to have access.

(m) Clinicians should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible.

(n) Clinicians should transfer or dispose of consumers’ records in a manner that protects consumers’ confidentiality and is consistent with state statutes governing records and provider’s licensure.

(o) Clinicians should take reasonable precautions to protect consumer confidentiality in the event of the clinician’s termination of practice, incapacitation, or death.

(p) Clinicians should not disclose identifying information when discussing consumers for teaching or training purposes unless the consumer has consented to disclosure of confidential information.

(q) Clinicians should not disclose identifying information when discussing consumers with consultants unless the consumer has consented to disclosure of confidential information or there is a compelling need for such disclosure.

(r) Clinicians should protect the confidentiality of deceased consumers consistent with the preceding standards.

8. Access to Records

(a) Clinicians should provide consumers with reasonable access to records concerning the consumers. When clinicians are concerned that consumers’ access to their records could cause serious misunderstanding or harm to the consumer, the rationale for withholding some or all of the record should be documented in consumers’ files.

(b) When providing consumers with access to their records, clinicians should take steps to protect the confidentiality of other individuals identified or discussed in such records.

9.  Respecting Boundaries

Clinicians should avoid accepting goods or services from consumers.  All relationships between the clinicians and consumers should remain professional and respectful at all times.  

10. Derogatory Language

Clinicians should not use derogatory language in their written or verbal communications to or about consumers. Clinicians should use accurate and respectful language in all communications to and about consumers.

11. Consumers Who Lack Decision-Making Capacity

When clinicians act on behalf of consumers who lack the capacity to make informed decisions, consumers should take reasonable steps to safeguard the interests and rights of those consumers.

12. Interruption of Services

Clinicians should make reasonable efforts to ensure continuity of services in the event that services are interrupted by factors such as unavailability, relocation, illness, disability, or death.

13. Termination of Services

(a) Clinicians should terminate services to consumers and professional relationships with them when such services and relationships are no longer required or no longer serve the consumers’ needs or interests.

(b) Clinicians should take reasonable steps to avoid abandoning consumers who are still in need of services. ) Clinicians should withdraw services precipitously only under unusual circumstances, giving careful consideration to all factors in the situation and taking care to minimize possible adverse effects. Clinicians should assist in making appropriate arrangements for continuation of services when necessary.

(c) Clinicians in fee-for-service settings may terminate services to consumers who are not paying an overdue balance if the financial contractual arrangements have been made clear to the consumer, if the consumer does not pose an imminent danger to self or others, and if the clinical and other consequences of the current nonpayment have been addressed and discussed with the consumer.

(d) Clinicians should not terminate services to pursue a social, financial, or sexual relationship with a consumer.

(e) Clinicians who anticipate the termination or interruption of services to consumers should notify consumers promptly and seek the transfer, referral, or continuation of services in relation to the consumers’ needs and preferences.

(f) Clinicians who are leaving an employment setting should inform consumers of appropriate options for the continuation of services and of the benefits and risks of the options.

Vendors, volunteers, and staff are required to sign a LCSC confidentiality agreement.

4. Procedures

Actions Staff member responsible

HIPAA training Outpatient director or designee

Consumer confidentiality all staff

Obtaining consents                                             all staff

Lakewood Community Services Corp. SMS/Texting

1. Introduction to our SMS/Texting
We value your privacy and are committed to protecting your personal information. This SMS/Texting Privacy Policy explains how we collect, use, and protect your information. By using our services, you agree to the terms of this policy.

2. Information We Collect
We may collect the following types of information:

• Personal Information: Information that can identify you, such as your name, email address, and phone number, when you voluntarily provide it to us.
• Non-Personal Information: Information that cannot be used to identify you, such as anonymous usage data, general demographic information, and referring/exit pages.

3. How We Use Your Information
We use the information we collect to:

• Provide and improve our services.
• Communicate with you.
• Understand how users interact with our services.

4. Information Sharing and Disclosure
We value your privacy and are committed to maintaining the confidentiality of your information.
We do not sell, trade, or otherwise transfer to outside parties your personal information.
We may share your information only under the following circumstances:
With Your Consent: We may share information with third parties if you give us your consent to do so. SMS opt-in consent is not shared or sold with third parties
For Legal Reasons: We may share information to comply with laws, regulations, legal processes, or governmental requests.

5. Data Security
We implement a variety of security measures to maintain the safety of your personal information.
However, no method of transmission over the Internet, or method of electronic storage, is 100% secure, and we cannot guarantee absolute security.

6. Your Rights
You have the right to:

• Access the personal information we hold about you.
• Request correction or deletion of your personal information.
• Object to the processing of your personal information.
• Withdraw your consent at any time.