Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective Date of This Notice: April 14, 2003

Who Will Follow This Notice: This notice describes the practices of our nursing facility and of the following persons and entities:

• Any health care professional authorized to enter information into your medical chart
• All departments and units of this facility
• Any volunteer and contractor who provides services to you while you are in our facility
• All employees, staff and other facility personnel
• The following classes of providers, suppliers and their employees: laboratories; physical, occupational, speech and respiratory therapy providers; transportation providers; radiology providers; pharmacies; audiology providers; dietary providers; and medical supply companies
• The following classes of individual health care providers: attending physicians; optometrists; ophthalmologists; dentists; podiatrists; psychologists; and psychiatrists

All of the persons and entities noted above will follow the terms of this notice with regard to your health information for services provided in our nursing facility or to you while you are a resident in our facility regardless of where the services are actually provided. In addition, these persons and entities may share your health information with each other for treatment, payment or other health care operations purposes as described in this notice.

How We Will Use or Disclose Your Health Information

Treatment. We will use your health information for treatment. For example, information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from our facility.

Payment. We will use your health information for payment. For example, a bill may be sent to you or a third-party payer, including Medicare or Medicaid. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

Health care operations. We will use your health information for regular health operations. For example, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.

In addition, we will disclose your health information for certain health care operations of other entities. However, we will only disclose your information under the following conditions: (a) the other entity must have, or have had in the past, a relationship with you; (b) the health information used or disclosed must relate to that other entity’s relationship with you; and (c) the disclosure must only be for one of the following purposes: (i) quality assessment and improvement activities; (ii) population-based activities relating to improving health or reducing health care costs; (iii) case management and care coordination; (iv) conducting training programs; (v) accreditation, licensing, or credentialing activities; or (vi) health care fraud and abuse detection or compliance.

Business associates. There are some services provided in our organization through contacts with business associates. Examples include accountants, consultants and attorneys. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associates to appropriately safeguard your information.

Directory. Unless you notify us that you object, we may use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.

Notification. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition. If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided us, e.g., on an answering machine.

Communication with family. Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Marketing. We may contact you regarding your treatment, to coordinate your care, or to direct or recommend alternative treatments, therapies, health care providers or settings. In addition, we may contact you to describe a health-related product or service that may be of interest to you, and the payment for such product or service.

Fundraising. We may contact you or your designated representative as part of a fundraising effort.

Other uses & disclosures. We may use or disclose your protected health information in the following situations without your authorization since these uses and disclosures are required or permitted by law without such authorization:

• As required by law
• For public health activities, such as reporting to the Federal Drug Administration or the Occupational Safety and Health Administration
• About victims of abuse, neglect or domestic violence
• For health oversight activities
• For judicial and administrative proceedings
• For law enforcement purposes
• About decedents, such as releases to coroners, medical examiners and funeral directors
• For cadaveric organ, eye or tissue donation purposes
• For research certain purposes where we have permission from an institutional review board or privacy board
• To avert a serious threat to health or safety
• For specialized government functions, such as national security
• For workers’ compensation

Your Health Information Rights

Although your health record is the physical property of the nursing facility, the information in your health record belongs to you. You have the following rights:

• You may request that we not use or disclose your health information for a particular reason related to treatment, payment, the facility’s general health care operations, and/or to a particular family member, other relative or close personal friend. We ask that such requests be made in writing on a form provided by our facility. Although we will consider your requests with regard to the use of your health information, please be aware that we are under no obligation to accept it or to abide by it. We will abide by your requests with regard to the disclosure of your clinical and personal records to anyone outside of the facility, except in an emergency, if you are being transferred to another health care institution, or the disclosure is required by law.
• If you are dissatisfied with the manner in which or the location where you are receiving communications from us that are related to your health information, you may request that we provide you with such information by alternative means or at alternative locations. Such a request must be made in writing, and submitted to the Social Services Director. We will attempt to accommodate all reasonable requests.
• You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by law. You may make such requests orally or in writing; however, in order to better respond to your request we ask that you make such requests in writing on our facility’s standard form. If you request to have copies made, we will charge you the community standard rate established by state law for copies of medical records requested from health care providers, such as hospitals and doctors.
• If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information. Such requests must be made in writing, and must provide a reason to support the amendment. We ask that you use the form provided by our facility to make such requests. For a request form, please contact the Privacy Officer.
• You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request (not to exceed 6 years). We ask that such requests be made in writing on a form provided by our facility. Please note that an accounting will not apply to any of the following types of disclosures: disclosures made for reasons of treatment, payment or health care operations; disclosures made to you or your Representative, or any other individual involved with your care; disclosures made pursuant to a valid authorization; disclosures to correctional institutions or law enforcement officials; and disclosures for national security purposes. You will not be charged for your first accounting request in any 12 month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost based fee.
• You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.
• You may revoke an authorization to use or disclose health information, except to the extent that action has already been taken. Such a request must be made in writing.

For More Information or to Report a Problem

If have questions and would like additional information, you may contact our facility Privacy Officer. If you believe that your privacy rights have been violated, you may file a complaint with us. These complaints must be filed in writing on a form provided by our facility. The complaint form may be obtained from Social Services, and when completed should be returned to Social Services. You may also file a complaint with the secretary of the federal Department of Health and Human Services. There will be no retaliation for filing a complaint.

Access to Medical Records

If you desire to obtain or if you would like someone else to obtain any information from your medical record, you are required to complete a written authorization form that authorizes the facility to disclose such information. These forms may be obtained from the Administrator or in their absence, the Director of Nursing. In addition, you or the person whom you authorize to access your information must pay for any copies that they request before those copies will be provided to them.

Privacy Act Statement

Federal law requires that we provide you with the following notice. We are required to comply with that law in order to receive any payment from Medicare or Medicaid for services provided to its residents. This form is not a consent form to release or use health care information pertaining to you.

1) Authority for collection of information including social security number (SSN) Sections 1819(f), 1919(f), 1819(b)(3)(A), 1919(b) (3)(A), and 1864 of the Social Security Act. Skilled nursing facilities for Medicare and Medicaid are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident’s functional capacity and health status. As of June 22, 1998 all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronically transmit this information to the State. The State is then required to transmit the data to the federal Central Office Minimum Data Set (MDS) repository of the Centers for Medicare and Medicaid Services (CMS). These data are protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records.

2) Principal purposes for which information is intended to be used The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing facilities that participate in Medicare or Medicaid. Submission of MDS information may also be necessary for the nursing facilities to receive reimbursement for Medicare services.

3) Routine uses The primary use of this information is to aid in the administration of the survey and certification of Medicare/Medicaid long term care facilities and to improve the effectiveness and quality of care given in those facilities. This system will also support regulatory, reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purpose. The information collected will be entered into the Long Term Care Minimum Data Set (LTCMDS) system of records, System No. 09-70- 1516. Information from this system may be disclosed, under specific circumstances, to:

(1) a congressional office from the record of an individual in response to an inquiry from the congressional made at the request of that individual;

(2) the Federal Bureau of Census;

(3) the Federal Department of Justice;

(4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease of disability, or the restoration of health;

(5) contractors working for CMS to carry out Medicare/Medicaid functions, collating or analyzing data, or to detect fraud or abuse;

(6) an agency of a State government for purposes of determining, evaluating and/or assessing overall or aggregate cost, effectiveness, and/or quality of health care services provided in the State;

(7) another Federal agency to fulfill a requirement of a Federal statute that implements a health benefits program funded in whole or in part with Federal funds or to detect fraud or abuse;

(8) Peer Review Organizations to perform Title XI or Title XVIII functions,

(9) another entity that makes payment for or oversees administration of health care services for preventing fraud or abuse under specific conditions.

4) Whether disclosure is mandatory or voluntary and effect on individual of not providing information For nursing facility residents residing in a certified Medicare/Medicaid nursing facility the requested information is mandatory because of the need to assess the effectiveness and quality of care given in certified facilities and to assess the appropriateness of provided services. If a nursing facility does not submit the required data it cannot be reimbursed for any Medicare/ Medicaid services.