8b - RECORDS RETENTION, FOLDER MAINTANCE, RESPONSIBILITY, AND ACCESS


Responsibility
The Director of Administration, is the privacy official designated for responsibility of the development and implementation of Recovery Works privacy policies and procedures.
The Administrator, Clinical Director, Director of Administration and Executive Director are authorized to determine what staff members may access confidential client records and are responsible for ensuring that such access is only made by such staff member whose job descriptions reflect a need to view confidential records.
Any disclosure of confidential information to a third party must be approved by the Administrator, Clinical Director, Director of Administration or Executive Director.
Policy

  1. Recovery Works shall not take any intimidating, threatening, coercive, discriminatory, or other retaliatory act against any individual who exercises rights under these Privacy Rules.
  2. Recovery Works shall not require patients to waive their right to complain about privacy violations to the Secretary of HHS or their other such rights as a condition of treatment.
  3. Recovery Works staff who do not follow privacy policies and procedures are subject to termination
  4. All active client records will be located in locked cabinets at the Recovery Works facility in a locked office, with the keys in the possession of the Administrator, Clinical Director, Director of Administration or Executive Director. The maintenance of the records is supervised by the Director of Administration.
  5. The Clinical Director will be responsible for determining which staff need access to which specific confidential client records and may restrict access to specific staff by informing the facility privacy official.
  6. To comply with Privacy Rule 45 CFR, documentation of these policies and procedures are maintained by Recovery Works in written or electronic form for 7 years from the date the document is created, or last effective, whichever is later.


Confidential Records Procedures

  1. All client program records are to be kept confidential at all times.
  2. Only clinical staff as determined by the Clinical Director shall have access to private medical information. The Clinical Director oversees according to the needs of the clients, in consideration of staff training and experience, which staff may be appropriately accessing patient files in any particular case, as monitored by the Administrator.
  3. All active client records will be located in locked cabinets at the Recovery Works facility in a locked office, with the keys in the possession of the Administrator and his or her designee. The maintenance of the records is supervised by the Administrator.
  4. Each client's program record will be proximately accessible and available to staff responsible for documentation review.
  5. File cabinets will be marked in such a manner that client's case files may be located easily by the staff.
  6. Any record removed from the facility will follow the client and will be signed out by the appropriate Recovery Works staff maintaining custody.
  7. Individual client program records shall be retained for a minimum of seven years. After 90 days post treatment, records may be stored in a locked storage facility. The disposition of client records shall be carried out in accordance with Federal Regulations.


Confidentiality of Identity and Program Participation
All clients enrolled at Recovery Works are accorded identity confidentiality by federal law.
All staff members are required to adhere to these rules and may be dismissed for allowing a breach of such client rights.
Telephone calls to Recovery Works for its clients shall be received by staff. The identity and enrollment of a client may be acknowledged only with a signed release of information (ROI) form, with such specific request identified.
For telephone acknowledgement of a client's presence or participation in the program, or, for the relaying of outside callers through staff to clients, each client must first sign a telephone release form, indicating specifically to whom, to which callers, Recovery Works may acknowledge the presence or participation of a client in its program.
If a client wishes to have all of their phone calls relayed regardless of the caller, they may stipulate such on their telephone release.
Otherwise, for any caller without a release, the proper response should be:

    • "(I am sorry, but) 'without written client permission, I can neither confirm nor deny whether anyone is, or has ever been, a client here with us'."

If questioned further:

    • "(I am sorry, but) 'that information is protected under federal law'."

Unacceptable responses include:

    • "That person was never here", (when they have been) or
    • "There is no one here by that name", (when there is).

At all times, including outside of their professional capacities, staff are to keep confidential any and all client data and information which is conveyed to them by a client or by any other staff member as provided by 42 CFR part 2 and Privacy Rule 45 CFR.