NOTICE OF INFORMATION PRACTICES
Effective Date: April 14, 2003

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.

If you have questions regarding this Notice, please contact our Privacy Officer at (540) 380-6524.

WHO WILL FOLLOW THIS NOTICE:
This Notice describes our facility’s information practices and that of:

• Any healthcare professional authorized to enter information into your clinical record;
  • All departments and units of Richfield Retirement Community;
  • Any member of a volunteer group we allow to help you while you are in the facility;
  • All employees, staff members, and physicians/specialists/physician’s assistants/nurse practitioners/healthcare consultants;
  • Any student (e.g. Certified Nursing Assistant classes, LPN classes) we allow to provide care to you while you are a resident in our facility;
  • All these entities, sites, and locations follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for treatment, payment, or healthcare operations as described in this Notice.
  All these entities, sites, and locations follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for treatment, payment, or healthcare operations as described in this Notice.
  We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at this facility. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by interdisciplinary team members in this facility. Your attending physician may have different policies or notices regarding his/her use and disclosure of your medical information created in the doctor’s office or clinic.
  This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of information.
  
  HOW WE USE AND DISCLOSE INFORMATION ABOUT YOU:
  FOR TREATMENT PURPOSES: In our ongoing efforts to provide quality of care, we may use your information to assure prompt and adequate medical diagnosis, treatment/medications/therapy, supplies, services and/or medical equipment. We may disclose health information to doctors, specialists (such as psychologists/psychiatrists, podiatrists, dentists, ophthalmologists, cardiologists, oncologists, nephrologists, etc.), pharmacists, nurses (including but not limited to licensed practical nurses, registered nurses, medication technicians, clinical nurse practitioners, etc.), certified nursing assistants, social workers, activities staff (including volunteers), dietary staff, diagnosticians (laboratory, x-ray, etc.), hospitals, transport company/ambulance service, and rehab therapists/assistants. For example, a doctor may need to tell the registered dietitian if you have diabetes so that we can arrange for appropriate meals/nutritional management for you. This disclosure may be within the facility or outside of the facility in either written, verbal, or electronic communications.
  
  Your photograph may be taken for both identification purposes and recording any special injury and/or treatment. For example, upon admission, your picture will be taken and placed in the medication/treatment notebook. With each medication/treatment pass, the nurse will check your identity with the picture to make sure the right medication or treatment is given to the right resident.
  
  We also may disclose medical information about you to people outside the facility that may be involved in your medical care currently or upon discharge. These people may include, but not limited to, clergy/pastor, family members, friends, and/or allied health professionals (such as vocational rehab, outpatient rehab or mental health services, “meals on wheels”, home health, etc.).
  
  Because of our relationship with Medicare and Medicaid programs, we must comply with certain professional standards of medical practice and licensure/certification. As a result of this relationship, as well as other corporate and regulatory processes, we may disclose clinical and personal information about you to the Centers for Medicare / Medicaid Services, State Department of Health, Ombudsman, Adult Protective Services, Corporate Quality Assessment and Assurance, etc. For example, the federal government requires that the nursing facility complete and transmit an electronic assessment (Minimum Data Set) about you to the State Department of Health and Centers for Medicare/Medicaid Services.
  
  FOR PAYMENT PURPOSES:
  We may use and disclose personal and medical information about you so that the healthcare services and treatment you receive may be collected from an insurance company and/or third party. For example, an insurance carrier (acting as a fiscal intermediary for the administration of Medicare benefits) may need birth date, social security number, and medical diagnoses and treatment to properly bill for these services. Likewise, if you are a member of the military, we may need to disclose certain medical and personal information to the Department of Veterans Affairs to determine if you are eligible for benefits.
  
  FOR HEALTHCARE OPERATION PURPOSES:
  We may use and disclose information about you for various types of healthcare and related administrative operations. These uses and disclosures are necessary for individual care and/or performance of our staff in certain types of illnesses/conditions. We may remove information that identifies you from this set of medical information so that others may use it to study healthcare and healthcare delivery without learning who the specific residents are. For example, we may combine medical information about a number of residents to decide what additional services the nursing facility should offer, what services are not needed, and whether certain new treatments or interventions are needed. We may also disclose information to medical equipment suppliers, orthotics/prosthetics, and/or audiologists, etc.
  
  FOR DIRECTORY PURPOSES:
  We may include certain limited information about you so that others may visit you, know your condition, or to facilitate healthcare operations. This information may include your name, room number, physician’s name, and general condition (such as fair, stable, poor, etc.). This type of information may be released to people who ask for you by name. Your religious affiliation may be released to a member of the clergy even if they don’t ask for you by name. Other examples of the use of directory information are; active medical chart binders may be stored at nursing stations, visible to the general public, which reveal your name, room number, and physician or care providers name. Similar information may be included on a scheduling board, white board or magnetic, reflecting appointments, current location, or other general information. Personal or provided items may be marked with your name to reflect ownership or use. Ledgers used to document the presence of care providers, sitters, etc., hired by you or your family may be maintained. Also, a posting of names/room numbers are available to the public to locate you within the facility.
  We may release information about you to a friend or family member who is directly involved and/or shown particular interest in your care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition. In addition, we may disclose information about you to help in a disaster relief effort so that your family/friends can be notified about your condition, status, and location.

FOR PUBLIC SAFETY OR HEALTH PURPOSES:
We may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of others. Any disclosure of this type, however, will be given only to someone who is able to prevent the threat.
We may release medical information related to resident health and safety risks or alleged violations. Accidents/incidents, grievances, medication errors (including but not limited to adverse drug reactions), and abuse/neglect will be thoroughly investigated and analyzed for causative factors/patterns and trends as well as prevention/action plans. This information will be disclosed internally and also to the medical director, ombudsman, and/or State reporting agencies.
FOR HEALTH OVERSIGHT ACTIVITIES:
We may disclose medical information to consultants or other agencies authorized by law or corporate policies. These oversight activities may include, but not limited to, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights and other state and federal laws.
FOR LAWSUITS AND DISPUTES:
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
FOR LAW ENFORCEMENT:
We may release medical information if asked to do so by a law enforcement official:
In response to a court order, subpoena, warrant, summons, or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at the nursing facility;
• In emergency circumstances to report a crime, the location of the crime or victims, or the identity and/or description or location of the person who committed the crime.
CORONERS, MEDICAL EXAMINERS, AND FUNERAL DIRECTORS:
We may disclose information to a coroner or medical examiner to identify a deceased person or determine the cause of death. We may also release medical information about residents of this nursing facility as necessary to carry out their duties.
YOUR RIGHTS REGARDING MEDICAL INFORMATION USES AND DISCLOSURES:
RIGHT TO REQUEST LIMITATIONS/RESTRICTIONS TO CERTAIN USES/DISCLOSURES: You have the right to request a restriction or limitation to the above-mentioned medical information we use or disclose about you for purposes of treatment, payment, and healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. EXAMPLE: You may not want your name and room number published in our posted (room door) and listed directory.
Certain information must be used and disclosed by this facility per mandated state and federal regulations. Therefore, you are prohibited from limiting these types of uses/disclosures which may interfere with payment, quality of care, and/of licensure.

We are not required to agree to your request for restrictions/limitations. If we do, however, agree with these restrictions/limitations, we will comply with your request.

RIGHT TO REVIEW/INSPECT/RECEIVE COPIES: You have the right to review or inspect your health information and receive photocopies of the information that may be used to make decisions about your care. Usually, this information includes both medical and billing records, but it does not include psychotherapy notes. To inspect and/or receive photocopies of your medical information, you must contact the health information management or medical records department of this facility. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.
Twenty-four (24) hours advance notice is required for review/inspection of your medical information. If you would like copies, it is necessary that you provide us with forty-eight (48) hours advance notice.

We may deny your request to review/inspect and receive copies in some circumstances. To assist you in the review of your information, we recommend that one of our team members (such as attending physician, nurse, social worker, or medical records director) review the information with you. This co-review would help you in locating information within the chart. It would also help in understanding the handwriting and medical terms written within the clinical record. We would also like to be able to follow-up on any concerns that you might have after the review/inspection of your information.

If you are denied access to the medical information, you may request that the denial be reviewed. An objective team of privacy-minded officials will review the request, and we will comply with the outcome of the review.
RIGHT TO AMEND/CORRECT:
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend or correct the information. You have the right to request an amendment/correction as long as the information is kept by the nursing facility. All requests for amendment/correction of medical information must be directed to the health information management or medical records department.
We may deny your request for an amendment if the record information:
• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not a part of the medical information kept by our nursing facility;
• Is accurate and complete;
• Is irrelevant to the issue/concern raised.
RIGHT TO AN ACCOUNTING OF DISCLOSURES:
You have the right to request an “accounting of disclosures”. This accounting is a list of the information which was disclosed about you. To request an accounting of disclosures, you must contact the health information manager or medical records department of this nursing facility. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free of charge. For additional lists, we may charge you for the costs of providing the list according to the “customary” or “nominal” copying charges.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS:
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you or your representative at work or by mail. Please contact the Medical Records Department to request such arrangements. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
RIGHT TO REVOKE:
You have the right to revoke this consent, in writing, except to the extent that the facility has already taken action in reliance thereon. Your revocation, however, may result in this facility’s inability to provide treatment, care, and services.
REPORTING COMPLAINTS/ALLEGATIONS:

If you believe your privacy rights have been violated, you may file a complaint with the facility or the Office for Civil Rights. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

REPORTING COMPLAINTS/ALLEGATIONS:
If you believe your privacy rights have been violated, you may file a complaint with the nursing facility or the Office for Civil Rights. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
To file a complaint with the nursing facility, contact:
Tim Mills, Privacy Officer, (540) 380-6524.
To file a complaint with the Office for Civil Rights, contact;
The Office for Civil Rights, U.S. Dept. of Health and Human Services,
150 S. Independence Mall West,
Suite 372, Public Ledger Building,
Philadelphia, PA 19106-9111,
or;
Main Telephone (215) 861-4441, Hotline (800) 668-1019, FAX (215) 861-4440,
TDD (215) 861-4440
CHANGES/REVISION TO THIS NOTICE:
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical 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 the facility.
OTHER USES OF MEDICAL INFORMATION:
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.