Documentation of Privacy Information Practices

This acknowledgement signifies the following:

  1. I have been provided with a copy of Shady Grove Center for Nursing and Rehabilitation Notice of PrivacyPractices.
  2. I have read and understand the Notice of PrivacyPractices.
  3. If I have questions about the Notice, I understand that I am able to contact Shady Grove Center for Nursing and Rehabilitation forclarification.

Please sign this acknowledgement and return it to Shady Grove Center as soon as possible.

______________________________________
Signature of Resident/Patient or Responsible Party

______________________________________
Date

Notice of Privacy Information Practices

Effective date: August 1, 2018

Revision date(s): April 1, 2019

This notice describes how medical information about youmay be used and disclosed and how you can get access to this information.

Please review it carefully.

A.  General description and purpose of this notice.

This notice describes our information privacy practices that cover our facility and the following people:

  1. Any health care professional or other health care provider authorized to enter information into your medical record created and/or maintained at ourfacility.
  2. Any member of a volunteer group which we allow to help you while receiving services at our facility and
  3. All facility employees, staff and other personnel.

All of the individuals or entities identified above will follow the terms of this notice. These individuals or entities may share your health information with each other for purposes of treatment, payment, or health care operations, as further described in thisnotice.

B.  Our facility’s policy regarding your health information.

We are committed to preserving the privacy and confidentiality ofyour health information created and/or maintained at our facility. Certain federal, state and local 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 our privacy practices and applies to all your health information created and/or maintained at our facility, including any information that we receive from other health care providers or facilities. The notice describes the ways in which we may use or disclose your health information and describes your rights and our obligations regarding any such uses or disclosures. We will abide by the terms of this notice, including any future revisions that we may make to then oticeas required or authorized by law.

We reserve the right to change this notice and to make the·revised or changed notice effective for the health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility in the reception area. The first page of this notice contains the effective date and any dates of revision.

C.  Uses or disclosures or your health information.

We may use or disclose your health. information in one of the following ways:

  1. Pursuant to your written consent (for purposes of treatment, payment or health careoperations).
  2. Pursuant to your written authorization (for purposes other than treatment, payment or healthcareoperations).
  3. Pursuant to your verbal agreement (for use in our facility directory or to discuss your health condition with Responsible Party, Guardian or Health Care Agents who are involved in yourcare)
  4. As permitted bylaw.
  5. As required bylaw.

The following describes each of the different ways that we may use or disclose your health information. Where appropriate, we have included examples of the different types of uses or disclosures. These examples are not intended to identify every type of use ordisclosure.

 1.  Uses or disclosures made pursuant to your written consent

We may use or disclose your health information for purposes of treatment, payment, or health care operations upon obtaining your written consent. We may condition our delivery of services to you upon receiving your consent.

a.  Treatment
We may use your health information to provide you with health care treatment and services. We may disclose your health information to doctors, Nurse Practitioners, nurses, nursing assistants, medication aides, technicians, students (medical, nursing, nursing assistant, medication aide), rehabilitation therapy specialists, laboratory personnel, orotherpersonnelwhoareinvolvedinyourhealthcare, or in connection with referrals among health care providers. For example, our nursing staff may need to talk with the physical therapist so that we can coordinateservicesanddevelopaplanofcare.Wealso may disclose your health information to peopleoutside ofourfacilitywhomaybeinvolvedinyourhealthcare, such as family members, social service organizations, homehealthagencies,orotherhealthcareproviders.

         i.  Appointment Reminders

We may use or disclose your health information for purposes of contacting you to remind you of an Interdisciplinary
Care Planappointment.

         ii. Treatment alternatives, health-related benefits and services

We may use or disclose your health information for purposes of contacting you to inform you of treatment alternatives or health related                        benefit sand services thatmaybeofinterest toyou.

b.  Payment

We may use or disclose your health information so that we may bill and collect payment from you, an insurance company, or another third party for the health care services you receive at our facility. For example, we may need to give information to your health plan regarding the services you received from our facility so that your health plan will pay us or reimburse you for the services. We also maytell your health plan about a treatment you are going to receive inorder to obtain prior approval for the services or to determine whether your health plan will cover the treatment.

c.  Health Care Operations

We may use or disclose your health information to perform certain functions within our facility. These uses or disclosures are necessary to operate our facility and to make sure that our residents receive quality care. For example, we may use your health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may review health information about a number of our residents collectively to determine whether certain services are effective or whether additional services should be provided. We may disclose your health information to physicians, nurses, nursing assistants, medication aides, rehabilitation therapy specialists, technicians, phlebotomists, medical and nursing students, funeral homes, Office of Health Care Quality, the Ombudsman and other personnel for review and learning purposes. We may also use information contained in your medical record in combination with information from other records so that others may use the information to study health care and health care delivery without learning the specific identities of ourresidents.

2.  Uses or disclose youres made pursuant to your written authorization

We may use or disclose your health information pursuant to your written authorization for purposes other than treatment, payment or health care operations and for purposes which are not otherwise permitted or required by law. You have the right to revoke a written authorization at any time as long as your revocation is provided to us in writing. If you revoke your authorization, we will no longer use or disclose your health information for the purposes identified in the authorization. You understand that we are unable toretrieve any disclosures which we may have made pursuant to your authorization prior to its revocation. Examples of uses or disclosures that may require your written authorization include thefollowing:

  1. Are quest to provide certain health information to a research project.
  2. Are quest to provide your health information to an attorney for use in a civil litigationclaim.

3.  Uses or disclosures made pursuant to your oral agreement

We may use or disclose your health information, pursuant to your oral agreement, for purposes of including you in our facility directory or for purposes of releasing information to persons involved in your care as described below.

  • Facility directory. We may use or disclose certain limited health information about you in our facility directory while you are a resident at our facility. This information may include your name, your assigned unit and room number, your religious affiliation, and a general description of your condition. Your religious affiliation may be given to a member or associate of the clergy. The directory information, except for religious affiliation, may be given to people who ask for you byname.
  • Individuals involved in your care. We may disclose your health information to individuals, such as Responsible Party, Guardian or Health Care Agent, who are involved in your care or in payment for your care. This disclosure will be limited to information that is relevant to matters in which your Responsible Party, Guardian or Health Care Agents are involved. We may also disclose your health information to a person or organization assisting in disaster relief efforts for the purpose of notifying your family and/or other persons responsible for your care about your condition, status and location.

We will not make these disclosures if you inform us that you object.

4. Uses or disclosures required/permitted by law.

Certain federal, state and local laws and regulations require or permit us to make certain uses or disclosures of your health information without your permission. These uses or disclosures are generally made to meet public health reporting obligation sort to ensure the health and safety of the public at large. The uses or disclosures which we may make pursuant to these laws and regulations include thefollowing:

a. Public health activities

We may use or disclose your health information to public health authorities that are authorized by law to receive and collect health information for the purpose of preventing or controlling disease, injury or disability. We may use or disclose your health information for the followingpurposes:

  • To reportdeaths.
  • To report suspected or actual abuse, neglect or domestic violence involving a child or anadult.
  • To report adverse reactions to medications or problems with health careproducts.
  • To notify individuals of productrecalls.
  • To notify an individual who may have been exposed to a disease or may be at risk for spreading or contracting a disease orcondition.

b. Health oversight activities

We may use or disclose your health information to a health oversight agency that is authorized by law to conduct health oversight activities. These oversight activities may include audits, investigations, inspections, licensure and certification surveys, or civil or criminal legal proceedings. These activities are necessary for the government to monitor the persons or organizations that provide health careto individuals and to ensure compliance with applicable state and federal laws and regulations.

c. Judicial or administrative proceedings

We may use or disclose your health information to courts or administrative agencies charged with the authority to hear and resolve lawsuits or disputes. We may disclose your health information pursuant to a court order, a subpoena, a discovery request, or other lawful process issued by a judge or other person involved in the dispute, but only if we are satisfied that efforts have been made to (i) notify you of the request for disclosure or (ii) obtain an order protecting your healthinformation.

d. Disclosures to an Employer

Under limited circumstances, we may disclose an individual’s health information to his or her employer in connection with the employer’s workplace-related medical surveillance or concerning a work-related illness or injury. Such a disclosure is governed by specific federal regulations that require, among other things, that we give notice to the patient of such adisclosure.

e. Workers’ Compensation

As permitted by federal regulations and Maryland law, we may disclose an individual’s protected health information as necessary to comply with workers’ compensationlaws

f. Law Enforcement Official

We may use or disclose your health information in response to a request received from a law enforcement official for the followingpurposes:

  • In response to a court order, subpoena, warrant, summons or similar lawfulprocess.
  • To identify or locate a suspect, fugitive, material witness, or missingperson.
  • Regarding a person who is or is suspected to be a victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement.
  • To report a death that we believe may be the result of criminalconduct.
  • To report criminal conduct at our facility.
  • Inemergencysituations,toreportacrime-thelocation of the crime and possible victims; or the identity, description, or location of the individual who committed the crime.

g.  Coroners, medical examiners, or funeral directors

We may use or disclose your health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We also may use or disclose your health information to a funeral director for the purpose of carrying out his/her necessary activities.

h.  Organ procurement organizations or tissue banks

If you are an organ donor, we may use or disclose your health information to organizations that handle organ procurement, transplantation, or tissue banking for the purpose of facilitating organ or tissue donation ortransplantation.

i.  Research

We may use or disclose your health information for research purposes under certain limited circumstances. Because all research projects are subject to a special approval process, we will not use or disclose your health information for research purposes until the particular research project for which your health information n1ay be used or disclosed has been approved through this special approval process. However, we may use or disclose your health information to individuals preparing to conduct the research project in order to assist them in identifying the residents with specific health care needs who may qualifyto participate in the research project. Any use or disclosure of your health information which may be done for the purpose of identifying qualified participants will be  conducted onsite at our facility. We will ask for your specific permission to use or disclose your health information if the researcher will have access to your name, address or other identifying information.

j.  To avert a serious threat to health or safety

We may use or disclose your health information when necessary to prevent a serious threat to the health or safety of youor other individuals. Any such use or disclosure would be made solely to the individual(s) or organization(s) that have the ability and/or authority to assist in preventing the threat.

k.  Military and veterans

If you are or were a member of the armed forces, we may use or disclose your health info1mation as required by military commandauthorities.

l.  National security and intelligence activities

We may use or disclose your health information to authorized federal officials for purposes of intelligence, counterintelligence, and other national security activities, as authorized bylaw.

D.  Your rights regarding your healthinformation

        You have the following rights regarding your health information which we create and/or maintain:

1. Right to inspect and copy

You have the right to inspect and copy health information that may be used to make decisions about your care. Generally, this includes medical and billingrecords, but does not include psychiatricnotes.

To inspect and copy your health information, you must submit your requestin writing tothe Medical Records Coordinator. If you request a copy of the information, we will charge afee for copying, mailing, or other supplies associated with your request.

We may deny your request to inspect and copy your health information in certain limited circumstances. If you are denied access to any part of your health information, you may request that the denial be reviewed. Another licensed health care professional selected by our facility will review your request and the denial. The person conducting the review will not be the person who initially denied your request. We will comply with the outcome of thisreview.

2. Right to request an amendment

If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for ourfacility.

To request an amendment, you request must be made in writing and submitted to the  Medical Records Coordinator. In addition, you must provide us with a reason that supports your request.We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (Note: This listing is NOT inclusive.)

  • was not created by us.
  • was created by the facility, but the person or entity that created the information is no longer available to make theamendment.
  • is not part of the health information kept by or for ourfacility.
  • is not part of the information which you would be permitted to inspect andcopy.
  • is accurate andcomplete.

3. Right to an accounting of disclosures

You have the right to request an accounting of the disclosures which we have made of your health information. This accounting will not include the disclosures of health information that we made for purposes of treatment, payment or health care operations or certain other disclosures made pursuant to your authorization or as permitted under the law.

To request an accounting of disclosures, you must submit your request in writing to the Medical Records Coordinator. Your request must state a time period which may not be longer than six (6) years prior to the date of your request and may not include dates before April 14, 2003. Your request should indicate in what form you want to receive the accounting (for example, on paper or via electronic means). At your request, we can provide you with one accounting without charge in a twelve-month period. If you request additional accountings, we will charge you for the costs of providing the accountings. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs areincurred.

4. Right to request restrictions

You have the right to request a restriction or limitation on the health information we use or disclose about your treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone, such as a family member or friend, who is involved in your care or in the payment of your care. For example, you could ask that wenot use or disclose information regarding a particular treatment that you received.

We are not required to agree to your request.If we do agree, we will comply with your request unless the information is needed to provide emergency treatment to you.

To request restrictions, you must make your request in writing to the Medical Records Coordinator. In your request, you must tell us (a) what information you want to limit; (b) whether you want to limit our use, disclosure or both; and (c) to whom you want the limits to apply (for example, disclosures to a family member).

5. Right to request confidential communications

You have the right to request that we communicate with you about your health care in a certain way or at a certain location.

To request confidential communications, you must n1ake your request in writing to the Medical Records Coordinator. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to becontacted.

6. Right to paper copy of this notice

You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of thisnotice.

To obtain a paper copy of this notice, contact the Medical Records Coordinator.

E.  Complaints

If you believe your privacy rights have been violated,you may file a complaint with our facility by contacting the Privacy Officer at (410) 646-6507. You may also file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing.

You will NOT be penalized or retaliated against for filing a complaint.