I. Rights under HIPAA
It will be explained that, under HIPAA, clients have the right to request restrictions on certain uses and disclosures of health information. The Center is not required to agree to any requested restrictions, but if it does agree then it is bound by that agreement and may not use or disclose any information which was restricted except as necessary in a medical emergency.
Under HIPAA, clients have the right to request either to inspect or have a copy made of personal health information maintained by the Center except to the extent that the information contains psychotherapy, case management notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances.
Under HIPAA, clients have the right, with some exceptions, to request an amendment to health care information, maintained in Center records, and to request an accounting of disclosures of health-related information made by the Center during the six years prior to the request. Clients may also have the right to receive a paper copy of this notice. To make any of the above requests, patients must complete the appropriate from that will be provided through the agency’s HIPAA Privacy Officer.
- The Center’s HIPAA Responsibilities: To comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). New York Center for Living defines mitigation as the act of causing an event or circumstance to become less harsh or hostile or making an event or circumstance less severe or painful.
- General HIPAA Requirements
Policy: To comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). New York Center for Living defines mitigation as the act of causing an event or circumstance to become less harsh or hostile or making an event or circumstance less severe or painful.
- New York Center for Living shall take positive reasonable action to minimize any known harmful effects resulting from the unauthorized use or disclosure of protected health information by New York Center for Living or its business associates and shall take steps to correct known instances of harm.
- Business associates shall be contractually obligated to notify New York Center for Living of any unauthorized use or disclosure of PHI and any harmful effects known to them. Business associates shall also bear the financial burden of any misuse of PHI by their employees or agents.
- Determination of the need for mitigation when PHI has been used or disclosed without authorization shall be determined on a case-by-case basis the Compliance/Privacy Officer of New York Center for Living with or without consultation with other senior leaders or legal counsel.
- The Center must obtain a written consent before it can disclose
- information about the client. Any such written consent may be revoked by the patient in writing.
- The consent for release of confidential information form must contain the following necessary elements as stipulated in the Federal confidentiality regulations:
- the name or general designation of the service(s) making the disclosure;
- the name of the individual or organization that will receive the disclosure;
- the name of the patient who is the subject of the disclosure;
- the purpose or need for the disclosure;
- how much and what kind of information will be disclosed;
- a statement that the client may revoke the consent at any time, except to the extent that the service has already acted in reliance on it;
- the date, event or condition upon which the consent expires if not previously revoked;
- the signature of the patient (and/or another authorized person); and
- the date on which the consent was signed.
II. Waiver of Rights Policy
New York Center for Living does not require clients to waive their rights in order to comply with HIPAA.
- In compliance with HIPAA regulations, New York Center for Living shall not require clients to waive their rights concerning treatment, payment, or health care operations.
- Any incidents of the above shall be reported immediately to the Director of Finance and Operations for corrective action and employee disciplinary measures.
III. Privacy Officer Policy
It is the policy of New York Center for Living to designate an individual as the Privacy Officer who is responsible for the knowledge and the implementation of the policies and procedures created as required by HIPAA regulations.
- New York Center for Living shall post a notice declaring the individual designated as the Privacy Officer in all sites or make this declaration in the posted Notice of Privacy Practices.
- The Privacy Officer will be responsible for New York Center for Living HIPAA compliance.
- The Privacy Officer’s duties will include the following at minimum:
- Obtaining and maintaining knowledge with current HIPAA regulations;
- Maintaining HIPAA compliant policies and procedures and updating these as required due to HIPAA modifications made by the Secretary of HHS;
- Educating and training current workforce members who have not received HIPAA training, and training new employees within 30 days of new hire;
- Maintaining an ongoing list of employees who have received HIPAA training;
- Dealing with all complaints and grievances (both employee and client) in relation to protected health information and HIPAA;
- Providing additional information on New York Center for Living Notice of Privacy Practices as requested.
- Any complaints received by the Privacy Officer will be dealt with according to the process set forth in the grievance policies and procedures or any other applicable policies and procedures.
- Another member of New York Center for Living staff may be designated to carry out the duties of the Privacy Officer. The qualifications of this person must be verified and documented by the Privacy Officer.
IV. Employee Access to PHI Policy
It is the policy of New York Center for Living to manage the use of client information by employees..
- New York Center for Living shall identify those employees who need access to specified types of protected health information to carry out their duties.
- New York Center for Living follows the policy that personnel are only permitted access to protected health information on a need to know basis.
- New York Center for Living shall make reasonable efforts to limit the access of such persons to only those categories of protected health information that have been so identified.
- Client Notification
- Upon admission, each client will be provided with a copy of the Client Rights and Grievance Procedures that is communicated in a way that is understandable to the client prior to the beginning of service delivery. Upon request, anyone may receive a copy of this policy and procedure statement.
- New York Center for Living shall make every effort to accommodate client differences in language and disabilities in accordance with applicable law.
- The Clients Rights Statement shall include contact information for the toll-free hotline to the New York State Vulnerable Persons’ Central Register, New York Center for Living’s Clinical Director/Medical
- Director, the OASAS Commissioner, the OASAS client advocate, and the OASAS toll-free telephone number.
- In crisis or emergency situations, the client will, at a minimum be advised of their immediate relevant rights.
- The Client Rights statement and the Client Grievance Procedure will be posted in a prominent area where clients and visitors may review them.
- Upon the client’s written request, New York Center for Living will forward information concerning the client’s grievance to any outside agent with approved signed releases.
- All staff will receive a copy of the Clients Right Policy and instruction in the Grievance Procedures upon employment with the Agency. Evidence that the employee received a copy of the Client Rights Policy and has agreed to abide by them, as well as evidence that he/she has been informed of client grievance procedure will be placed in the employee’s personnel file.
- A copy of both the Grievance Procedure and Clients Right Policy, dated and signed by the client, will be kept in each file to indicate receipt.
- New York Center for Living will maintain records of written grievances for at least two (2) years. These records will include:
- Copy of the grievance.
- Documentation reflecting process used and resolutions/remedy.
- Copy of the letter to the client reflecting resolution of the grievance.
- Documentation of extenuating circumstances for extending time period for resolving grievance beyond 21 calendar days.
- The program shall demonstrate knowledge of the legal status of the client and when applicable, will provide information to the client regarding resources related to their legal status.
- Client rights will be communicated to each client at least annually and documented for those in services for longer than one (1) year.
V. Grievance Procedure Policy
It is the policy of New York Center for Living to have an established mechanism in addition to grievance procedures to resolve conflicts which may arise between the client and New York Center for Living personnel, and/or his/her parent/guardian/custodian concerning treatment issues and is based on OASAS and CARF requirements. The Client Rights Advocate will be responsible for ensuring the implementation and maintenance of the client grievance procedure
- Complaint and Grievance Definitions:
- Complaints and grievances are similar in some ways, but also have important differences. Complaints are to be made when a client wants to express their opinion that something has been done or some condition exists that they feel is not reasonable or which causes them discomfort or inconvenience. For example, one may complain that the waiting room is too warm, or that the staff was disrespectful, or that New York Center for Living’s clinic rules are too restrictive, and so on. Complaints can be verbal or in writing and can be given to a specific staff person or put in the suggestion box. If the person you initially complain to does nothing to address your concern, you have the option to take your complaint to higher level staff including the Clinical Director/Medical Director. In such cases, the complaint should be in writing.
- In contrast, grievances are always to be made in writing and are restricted to the following subject areas:
- The client believes there is a violation of law or regulation regarding his/her treatment at the facility or by facility staff. Examples can include violations of civil rights, sexual harassment, use of unqualified staff, and so on.
- The client believe that decisions made regarding his/her treatment or services violate the agency’s own policies in an unfair or prejudicial manner. For example, you believe that New York Center for Living is denying you services or terminating your services contrary to the rules, New York Center for Living is charging you fees other than what the rules/fee schedules require, the organization refuses to tell you your medication dose, or other such matters which are contrary to existing New York Center for Living policies.
- Upon admission, each client will be provided with a copy of the client grievance procedures. Upon written request, any other person may receive a copy of the policy and procedure. Receipt of the client grievance procedure is documented by client’s dated signature in his/her individual client record.
- If conflict between a client and his/her parent/legal guardian and/or New York Center for Living arises the primary clinician will first attempt to facilitate a resolution.
- Should a resolution at this level not occur, the clinician’s supervisor will intervene and assist in seeking resolution.
- All grievances must be written, signed and dated by the client or the person filing the grievance on behalf of the client and should include the date, approximate time, description of the incident and names of the individuals involved in the incident/situation being grieved. Grievances should be given to the Client Rights Advocate, or in the event the Client Rights Advocate is not on premises, the grievance can be given to the Corporate Compliance Officer. Any program supervisor will assist you in filing a grievance upon your request. All grievances, including a copy of the grievance, documentation reflecting the process used and resolution/remedy of the grievance and documentation, if applicable, of extending the time period for resolving the grievance beyond twenty-one (21) calendar days will be kept on file two years from resolution and will include a copy of the grievance, documentation reflecting the process used and resolution/remedy of the grievance and documentation, if applicable, of extenuating circumstances for extending the time period for resolving the grievance beyond twenty- one (21) calendar days.
- Within three (3) working days of receiving the grievance Client Rights Advocate will provide the client with written acknowledgement that includes:
- The date the grievance was received
- A summary of the grievance
- An overview of the grievance investigation process
- A timetable for completing the investigation and notification of the resolution, and
- The treatment provider contact person’s name, address and telephone number.
- If a problem cannot be resolved at a staff level, any client or family member may initiate a grievance at his/her discretion by requesting a grievance form from any staff person. Should the client need assistance in completing the grievance form, Clients Right Advocate will assist in the preparation and filing of a grievance. All grievances will be submitted to the Compliance Officer.
- The Clients Right Advocate will attempt to bring about a resolution to the client’s complaint and provide the client with a written and oral explanation of the resolution within seven (7) working days of the initiation of the client’s complaint.
- If after following this step you are still not satisfied, the client may appeal to the Compliance Officer within five (5) working days of receiving the decision of the Clients Right Advocate.
- Within five (5) working days of the client’s appeal, the Compliance Officer will schedule a time to meet with the client to discuss the client’s complaint.
- Within four (4) working days of the client’s meeting with the Compliance Officer, you will be provided, in writing, the Compliance Officer’s determination regarding the client’s complaint.
- A final resolution decision will be made within 21 calendar days of receipt of the complaint.
- All grievances must be signed and dated by the client or person completing the grievance form, and include the date, time, description of the incident, and the names of the individuals involved. The Clients Right Advocate will make a grievance resolution within twenty-one (21) days of receipt and notify the grievant by letter.
- Any exceptions that cause this time period to be extended will be documented in the grievance file and written notification will be given to the client or persons filing grievances on the client’s behalf. Upon the client’s written request to the Clients Right Advocate, the client has the option of filing a grievance with an outside organization.
- New York Center for Living will maintain for two (2) years the records of written grievances. These records will include a copy of the grievance, documentation of the grievance resolution, and a copy of the letter to the grievant reflecting the resolution. An analysis of all formal grievances/ complaints is conducted annually and documents New York Center for Living Policy and Procedures Manual January 2020 whether formal grievances/ complaints were received, any trends identified, areas need performance improvement, actions to be taken to address the improvements needed, and actions or changes made to improve performance.
- Both client and his/her family members may utilize the existing grievance procedures, if desired. The person served may make a formal complaint, file a grievance, or appeal a decision made by New York
- Center for Living staff members or team that specifies the following:
- That action will not result in retaliation or barriers to service;
- How efforts will be made to resolve the compliant;
- How the procedures for review will be explained to the persons served in a manner that is understandable
- Levels of review and availability of external review;
- Time frames that are adequate for prompt consideration and that result in timely decisions for the person served;
- Procedures for written notification regarding the actions to be taken to address the complaint;
- The rights and responsibilities of each party;
- The availability of advocates for other assistance;
- Grievance forms and procedures are made readily available to the persons served.
- The Clients Right Advocate will arrange for annual mandatory staff training on the client’s grievance procedure.
- At any time, clients or persons filing grievances on the client’s behalf have the right and option of the griever to initiate a complaint with any or all of several outside entities, including the toll-free hotline to the Vulnerable Persons’ Central Register, New York Center for Living Medical Director, the Commissioner of OASAS, the OASAS Client Advocate, the OASAS toll free telephone number, and CARF International.
The Clients Right Advocate for New York Center for Living is Geoffrey Golia, LCSW, and is available to assist you in filing and investigating your grievance. In his absence, or if he is the subject of a grievance, this grievance may be filed with Corporate Compliance Officer, Manuel Moscoso, CASAC II.
The Clients Right Advocate may be reached at:
New York Center for Living
226 East 52nd Street
New York, NY 10022