Driftwood Recovery Policy & Procedure

Subject: Confidentiality

Reference: §448.210

Pages: 3

Issued: 11/01/2014

Revised: 07/15/2016

Policy

Driftwood protects the privacy of individuals served. Federal confidentiality regulations regarding substance addiction treatment are very specific and override any conflicting state/local mandates. There are also strict resident/therapist restraints on disclosing resident identity and related clinical and health information that applies to our resident. These laws and regulations exist to provide residents with the assurance that their problems, their treatment, and their confidences will not be disclosed to anyone without their prior knowledge and consent unless records are under an issued subpoena and court order.

Confidentiality is not under the Duty to Warn clause allowing disclosure of information in cases where prevention of or lessening imminent, serious threat to the health or safety of person served or for a crime on the premises or against program personnel.

These resident rights are incorporated in the following policies:

  1. Phone Inquiries – Telephone inquiries regarding a resident’s participation in treatment typically comes from significant others and family members. Releasing any information to a third party may only be done with prior, written consent of the resident. This includes information related to resident enrollment in treatment, presence on site, urine screen results, attendance, and contents of individual and group sessions.
  2. Written Releases – Any information regarding a resident currently or in the past receiving treatment from Driftwood may only be released with prior, written consent from the resident. Written consents should specify the party to whom the information is to be released, the type of information to be released and a time limit for the effectiveness of the release. The release should be signed by the resident and witnessed by the counselor.
    • Any release of information of should be documented in the resident’s case record.
  3. Resident Records – All resident records should be maintained in the Electronic Medical Record (EMR) systems records online, or in locking file cabinets and/or behind locked doors. Written permission must be obtained by the resident before any records can be released. Requests for information from most sources (including subpoenas and court orders) should follow clinical protocols for Responding to a Request for Resident Records. No records are to be released without consent unless it is mandated by the courts with an appropriate court order. Every effort should be made to verify the authenticity of the resident signature by speaking with the resident prior to releasing the records if an authorization for records is received by an outside source. All resident charts are maintained in EMR systems or a locked facility for six (6) years and the sixth year after a resident’s18th birthday (see Policies and Procedures on Safeguard of Records). Duplicate information is maintained in the resident chart or shredded to protect confidentiality. Disposal of resident records after the sixth year will occur by destroying all paper documents or electronic records.
    • Additional disclosures of residents’ privacy information are prohibited unless authorized in writing by the resident. Driftwood cannot and will not use resident information in directories, marketing materials, and fundraising materials or events. Clinical notes are protected under the current federal laws (Title 42, Sections 2.1 — 2.67-1, Code of Federal Regulations) and should be protected by Driftwood.
    • All records revealing resident identities must always be protected from public view. Further information regarding clinical situations and confidentiality can be found in the clinical protocols.

Procedure

  1. Business matters should not be discussed in the open areas, waiting rooms, and hallways of Driftwood facilities. Discussions regarding residents or other Driftwood business should occur in private offices behind closed doors or in some other location where confidentiality is guaranteed. Discussions should be done quietly to ensure professionalism and the protection of our residents.
  2. Driftwood ensures that confidential information acquired during delivery of services will be safeguarded from illegal or inappropriate use, access and disclosure from loss, destruction or tampering. All written or taped material regarding residents must be guarded with utmost caution. These include: charts; weekly therapists caseload sheets; UA results; phone messages; letters; audio or video tapes; supervision notes; and evaluation/treatment forms. Resident records are to be stored in the EMR systems or locking cabinets. Disposal of records should be done in a manner that maintains confidentiality. No verbal or written information regarding Driftwood residents, including the fact that the individual is or has been a resident at the office, may be given in any form to anyone who is not a Driftwood staff member without direct written permission (release) from the resident.
  3. Driftwood clinical and non-clinical staff do not disclose resident confidences, including the names or identities of their residents, to anyone except:
    1. as mandated by law via a signed court order;
    2. as permitted by law (including medical emergencies);
    3. where a Driftwood is a defendant in a civil, criminal or disciplinary action arising from the treatment (in which case resident confidences may only be disclosed in the course of that action and following the procedures outlined in the “Confidentiality Policy”); or
    4. if there is a release previously obtained in writing, and then such information may only be revealed in accordance with the terms of the release. All residents entering treatment are given at intake and requested to sign a Notice of Confidentiality which outlines the above stated Federal Confidentiality Law and Regulations. The original Notice of Confidentiality is maintained in the resident’s chart and a copy is given to the resident.
  4. Driftwood clinical and non-clinical staff will never access, use or disclose any confidential health or personal information of any family member, friend, relative, co-worker or significant other who may be a resident of a Driftwood facility. In the event a counselor or staff member has a family member, friend, relative, co-worker, or significant other who is a resident of Driftwood the counselor or staff will provide written acknowledgement of his/her agreement to respect the confidentiality of the individual receiving services at a Driftwood by signing the Acknowledgement of Confidentiality form upon hire.
  5. Driftwood considers telecommuting to be a viable alternative work arrangement in cases where individual, job and supervisor characteristics are best suited to such an arrangement. Telecommuting allows an employee to work at home for part of their regular workweek. Telecommuting is a voluntary work alternative that may be appropriate for some employees and some jobs. It is not an entitlement; it is not a company-wide benefit; and it in no way changes the terms and conditions of employment with the employee’s respective Driftwood facility, including upholding all confidentiality standards of the organization and within this policy.
  6. Driftwood consultants and volunteers will not discuss or divulge information obtained in clinical or consulting relationships except in appropriate settings and for professional purposes that demonstrably relate to the case.
  7. Driftwood clinical staff use clinical materials in teaching, writing and public presentation only if a written release has been received or when appropriate steps have been taken to protect resident identity.
  8. In circumstances where more than one person in a family is receiving therapy and where a third party seeks information related to any aspect of such treatment, each family member receiving treatment who is legally competent to execute a release must sign the release before facility clinical or non-clinical staff will disclose information received from any family member.
  9. All information shared within therapeutic groups at a Driftwood is confidential and may not be released without prior, written consent from the resident(s). Residents participating in clinical group services are routinely reminded after every session to keep information shared during groups confidential. Residents who do not respect other residents’ confidentiality may be expelled from a group and/or treatment at each Driftwood facility. Entrance doors are secured 15 minutes after group start time to further ensure confidentiality.
  10. Driftwood will not disclose confidential information without expressed written consent, except as permitted or required by State and Federal laws.
  11. Driftwood Board of Directors, facility staff, and volunteers will remain knowledgeable of, and obey, all State and Federal laws and regulations relating to confidentiality of records relating to the provision of services.
  12. Driftwood staff and volunteers will not discuss or divulge information obtained in clinical or consulting relationships except in appropriate settings and for professional purposes that demonstrably relate to the case.
  13. Each Driftwood ensures that confidential information acquired during delivery of services will be safeguarded from illegal or inappropriate use, access and disclosure or from loss, destruction or tampering.
  14. Each Driftwood ensures that these safeguards protect against verbal disclosure, prevent unsecured maintenance of records, or recording of an activity or presentation without appropriate releases.