Patient Protected Health Information (PHI) Policy

In the course of delivering its services and programs, La Fuente Hollywood Treatment Centers collects personal information from its clients. Personal information means any information that could be used on its own, or with other information, to establish the identity of a client, the client’s service provider or the client’s substitute decision maker. Personal information also includes any other information about a client including information that is contained in a client record. All information, documents, and other files created will be managed in accordance with HIPAA standards.

La Fuente Hollywood Treatment Centers collects, uses and shares client’s personal information for the following purposes:

  • Providing quality programs and services to clients.
  •  Providing information to other people or organizations with client consent (for example, making a referral for service)
  • Contacting clients, donors and members to evaluate La Fuente Hollywood Treatment Centers service and work.
  • Conducting research to understand the kinds of issues our clients are facing.
  • Contacting individuals about our fundraising and membership activities.
  • Reviewing client files to ensure high quality of service and documentation.

 La Fuente Hollywood Treatment Centers may also collect, use and share personal information with consent or as permitted or required by law.

La Fuente Hollywood Treatment Centers is committed to protecting the privacy of its clients and ensuring that:

  • the personal information it receives from clients is kept safe, secure, confidential, accurate and up to date
  • clients understand why their personal information is collected by La Fuente Hollywood Treatment Centers.
  •  La Fuente Hollywood Treatment Centers obtains client consent before collecting, using, sharing or releasing client information, except as set out in this policy or permitted or required by law.
  • only the personal information necessary for the purposes listed above is collected from clients, unless otherwise consented to by the client or permitted or required by law.
  • access to client information is limited to the La Fuente Hollywood Treatment Centers Staff and Interns involved in delivering services to clients.
  • any external agents to whom La Fuente Hollywood Treatment Centers releases information have a need to know and only use and disclose client information for the purposes for which it was originally provided
  • clients are able to withdraw their consent at any time to the collection, use and disclosure of their personal information
  •  clients have access to their record, except where La Fuente Hollywood Treatment Centers is entitled to refuse an access request, and are able to copy or correct their record and ask questions about La Fuente Hollywood Treatment Centers privacy policies and procedures.
  • complaints about La Fuente Hollywood Treatment Centers privacy policies and procedures are handled efficiently and effectively.
  • all legal and regulatory requirements regarding client information are met and maintained

PROCEDURES

1.  Obtaining Consent

 As La Fuente Hollywood Treatment Centers services often involve collaboration and consultation among Staff, La Fuente Hollywood Treatment Centers Staff will discuss the following with new clients:

  • the nature and extent of consultation and collaboration in the La Fuente Hollywood Treatment Centers program or service which the new client is accessing.
  • the personal information that La Fuente Hollywood Treatment Centers may collect
  • the purposes for which La Fuente Hollywood Treatment Centers collects, uses and shares personal information, as listed above.
  • Client’s rights and responsibilities including rights related to keeping client’s personal information private will be reviewed with all new clients at their first appointment following intake.
  • Clients will be asked to use a form indicating that the organization’s privacy policies have been discussed and that the client consents to the collection use and sharing of personal information for the purposes listed in this policy.
  • The signed forms will be maintained by the program (e.g., in the client’s paper record, filed centrally within the program). A note will be made in the client’s electronic record that the form has been signed.
  • In cases where it is not possible or practicable to obtain the client’s written acknowledgment (e.g., telephone only service), verbal acknowledgment that the organization’s privacy practices have been explained to, and accepted by, the client will be recorded in an activity note in the client’s record.
  • Consent will be that of the individual and must be knowledgeable, relate to the personal information and not be obtained through deception or coercion. A consent to the collection, use or sharing of personal health information about an individual is knowledgeable if it is reasonable in the circumstances to believe that the individual knows, (a) the purposes of the collection, use and/or disclosure, as the case may be; and (b) that the individual may give or withhold consent.

In the event that Staff are concerned that a client does not have the capacity to consent to the collection, use and disclosure of his or her personal information, Staff should:

  • Consider whether the client understands the decision they are being asked to make.
  • Question whether the person understands the reasonably foreseeable consequences of the decision or lack of decision.
  • Consult with the Clinical Director.

2.  Client Withholding, Limiting or Withdrawing Consent

  • Clients have the right to stipulate who will have access to their personal information. This means that they can withhold, limit or withdraw their consent to the collection, use or disclosure of personal information. The request may cover all or a specific part of a client’s record. When this happens, staff will implement the following “lock-box” procedure.
  •  Electronic records: The La Fuente Hollywood Treatment Centers employee receiving the client’s request to withhold, limit or withdraw their consent will:
    • Record the verbal instructions by the client in an activity note in the client’s electronic record.
    • Scan any written instructions by the client into the client’s electronic record.
    • Notify the Associate Executive Director of the client’s instructions and they will limit access to the electronic record in compliance with the client’s request (e.g., closing access to the record; limiting access to the individuals specified by the client to be allowed access).

Paper records: If the client also has a paper file:

  • The client’s file (either in whole or in part depending on the client’s instructions) to which access is to be limited will be placed inside an envelope that will be sealed with the instructions from the client stapled to the outside of the file. If the client’s request is to withdraw consent, the file will be safeguarded by La Fuente Hollywood Treatment Centers Privacy Officer. If the client’s request is to withhold or limit consent, the Associate Executive Director responsible for the program will determine how best to comply with the client’s request.
  •  In cases where the withholding, limiting or withdrawal of consent will limit or prevent La Fuente Hollywood Treatment Centers from continuing to deliver services, Staff will discuss with the client the consequences of their withholding, limiting or withdrawal of consent.

3.  Higher Levels of Confidentiality (Use of Aliases)

  • La Fuente Hollywood Treatment Centers serves clients periodically that require a higher level of confidentiality. For example: public figures; staff of La Fuente Hollywood Treatment Centers funder; former staff and Interns, who may not wish it to be known that they are accessing La Fuente Hollywood Treatment Centers services.
  •  In such situations, programs will provide clients an opportunity to select and use an alias. The alias will be used in the client record and in the client’s interactions with La Fuente Hollywood Treatment Centers.
  • A list of the aliases, clients’ real names and file numbers will be confidentiality maintained by a designated person in each department with a copy to the La Fuente Hollywood Treatment Centers Privacy Officer.
  • A higher level of confidentiality designation does not invalidate the normal legal limits to confidentiality, which includes subpoenas, search warrants and the right of government funders to audit client records. Clients must be informed of these limitations on confidentiality.
  • The Director of Operations will provide names of new staff members, Interns and Counsellors to the La Fuente Hollywood Treatment Centers Privacy Officer so that a check of the client database can be completed. If the individual has received service from La Fuente Hollywood Treatment Centers in past, an alias will be assigned to the record in order to maintain the privacy of the new staff member, volunteer or Counsellors.

4.  Disclosure without Consent Including Responding to Summons/Subpoenas/Court Orders and Requests from Police

 La Fuente Hollywood Treatment Centers will not disclose the personal information of clients without their consent, except where:

  • It is believed the client or someone else is in imminent danger of serious physical harm (see Tarasoff v. Regents of University of California, 17 Cal.3d 425, 131 Cal.Rptr. 14, 551 P.2d 334; 1976; Ewing v. Goldstein 15 Cal. Rptr. 3d 864; Section 56.10(c)(19) of the Civil Code).
  • A child under the age of 18 is at risk of or has been abused or neglected (see California Penal Code Section 11166.5—11166.7).
  •  La Fuente Hollywood Treatment Centers is subpoenaed or is otherwise served with a court order, summons, warrant or a similar requirement issued by a person who has jurisdiction to compel the production of information in a proceeding.
  • It is otherwise permitted or required by law or in a manner compliant with HIPAA.

 If La Fuente Hollywood Treatment Centers employee or Intern is served with a warrant, summons, subpoena, order or similar requirement issued in a proceeding, the individual must immediately notify their Clinical Director, who will provide advice and direction as to how to respond. La Fuente Hollywood Treatment Centers Staff or Interns should follow the same procedure in response to requests by police officers for client information.

 In general, where an order, summons, warrant, subpoena or other requirement to produce documents has been served on La Fuente Hollywood Treatment Centers, La Fuente Hollywood Treatment Centers will:

  • Make every attempt to respond in a way that is respectful of the order or other requirement, while at the same time taking steps to preserve the client’s right to confidentiality.
  • Make an exact copy of the file to remain at La Fuente Hollywood Treatment Centers and deliver the documents to the court or other proceeding in a sealed enveloped marked “private and confidential”.

Where La Fuente Hollywood Treatment Centers discloses personal information without the client’s consent, the client will be notified of such disclosure as soon as reasonable, practical, safe and/or legally possible in the circumstances.

5.  Release of Information with Client Consent

Subject to Section 4, personal information, whether all or part of a client record, will not be released to third parties without the written consent of the client or the client’s substitute decision maker, where applicable. Clients are required to complete the La Fuente Hollywood Treatment Centers Authorization to Request or Release Information Form, depending on the nature of the request. Consents provided on these forms are valid for one year, unless otherwise limited or withdrawn by the client in advance of that date. La Fuente Hollywood Treatment Centers may disclose a client’s personal information, provided that the disclosure, to the best of La Fuente Hollywood Treatment Centers knowledge, is for a lawful purpose.

 Reports from third parties contained in a client record may not be released without the written consent of the third party. Clients will be encouraged to pursue access to this information directly with the third party.

 In exceptional circumstances, where written consent is not possible, the oral consent of the client to the release of personal information will be accepted and will be recorded in the client’s file.

In response to requests to release information to third parties, the La Fuente Hollywood Treatment Centers service provider will ensure that the client understands the purpose for which the information is being released and to whom the information is being released. The La Fuente Hollywood Treatment Centers service provider will also explain that La Fuente Hollywood Treatment Centers cannot guarantee the confidentiality of the information once it has been released.

6.  Safeguarding of Personal Information

Client information stored electronically is protected by passwords and other safeguards requested by HIPAA standards. Access to the La Fuente Hollywood Treatment Centers electronic database is limited on a need to know basis for added security.

Client information collected in hard copy form is stored in locked cabinets accessible only by the counsellors or other La Fuente Hollywood Treatment Centers Staff and Interns providing service to the client, and the relevant program Program Directors. Access to client information will be limited to those who need to know the information for the purposes set out in the client’s consent or as otherwise permitted or required by law.

 La Fuente Hollywood Treatment Centers Staff will never leave client personal information, in paper or electronic form, unattended or exposed to anyone other than the client.

La Fuente Hollywood Treatment Centers will not send confidential personal information to clients by email without the client’s prior consent. Personal information sent to clients or about clients will employ secure email. (Note that secure e-mail ensures messages are encrypted. La Fuente Hollywood Treatment Centers regular e-mail program is not secure email.).

Web-based counselling will use an encrypted website to protect client privacy and confidentiality.

La Fuente Hollywood Treatment Centers requires external agents, such as third party auditors, to maintain the confidentiality of client information and to refrain from using client information for any purpose other than the purposes for which consent was provided by the client. Where appropriate and necessary, La Fuente Hollywood Treatment Centers will obtain the consent of the client to disclosure of information to external agents. (External agents are persons or companies with which La Fuente Hollywood Treatment Centers has contracts and that may come into contact with personal information.)

 When disposal is permitted or required, records of client personal information will be disposed of in a secure manner such that reconstruction of the records is not reasonably foreseeable in the circumstances.

7.  Notice to Clients of Theft, Loss, Unauthorized Access, Use or Disclosure of Personal Information

Staff are required to report to their immediate supervisor and to the La Fuente Hollywood Treatment Centers Privacy Officer any theft, loss, unauthorized access, use or disclosure of personal information of La Fuente Hollywood Treatment Centers clients. In programs where funders require it, Clinical Director will file a serious occurrence report in this situation.

In the event of such theft, loss, unauthorized access, use or disclosure of personal information of a La Fuente Hollywood Treatment Centers client, La Fuente Hollywood Treatment Centers will notify the client as soon as possible.

Oral contact with the clients will be logged in the client record and will be followed up by a letter, which will be included in the client record.

In the case of former clients, contact will be made orally, if possible, and also in writing, at the last known address for the client recorded in La Fuente Hollywood Treatment Centers database.

8.  Client Access to and Correction of Personal Information

Clients wishing to review their records should contact the La Fuente Hollywood Treatment Centers service provider, relevant Program Director, or Privacy Officer.

Within 30 days of any such request, an appointment will be made for the client to review his/her personal information in a confidential manner on La Fuente Hollywood Treatment Centers premises, in the presence of a La Fuente Hollywood Treatment Centers employee, unless La Fuente Hollywood Treatment Centers is entitled to refuse the request, in which case written notice will be given. Clients may bring a support person to this appointment if they wish. Up to 60 days may be required in the case of complex searches for records. In exceptional circumstances (e.g., a client is unable to come to the La Fuente Hollywood Treatment Centers office due to health issues), a copy of the record may be sent to the individual with consent.

 La Fuente Hollywood Treatment Centers is required to retain client personal information that is the subject of a request for access for as long as necessary to allow the client to exhaust any recourse under the Personal Health Information Protection Act, 2004 that he or she may have with respect to the request. This may require La Fuente Hollywood Treatment Centers to maintain the record for longer than the typical client record retention period.

Clients who wish an explanation of their records may contact their La Fuente Hollywood Treatment Centers service provider, the relevant program Program Director or the La Fuente Hollywood Treatment Centers Privacy Officer.

Clients will not be permitted to access third party records without the consent of the third party. In such cases, the La Fuente Hollywood Treatment Centers service provider will direct the client to obtain the requested information directly from the third party.

Clients wishing to correct information in their file shall provide the correction in writing to La Fuente Hollywood Treatment Centers. The written correction will be included in the client’s record and, within three weeks of receipt, La Fuente Hollywood Treatment Centers will notify the client of its response to the correction.

9.  Appointment of Privacy Officer

The Privacy Officer for La Fuente Hollywood Treatment Centers is Anil Patel, contact info: 323-464-2947, anilpatel@lafuentehollywood.com

The name and contact information for the Privacy Officer is available on the La Fuente Hollywood Treatment Centers website, in the Client Rights and Responsibilities Statement and in the La Fuente Hollywood Treatment Centers Staff Directory. The duties of the Privacy Officer include:

  • Maintaining knowledge of privacy legislation and regulations.
  • Ensuring that all Staff and Interns have training on the privacy policy.
  • Monitoring employee compliance with La Fuente Hollywood Treatment Centers privacy policy. 
  • Responding to privacy-related complaints and concerns.
  • Responding to requests for access and correction.
  • Responding to inquiries from the public about La Fuente Hollywood Treatment Centers privacy practices.
  • Liaising with other organizations, the public and government, as necessary, on privacy-related issues

10.  Inquiries and Complaints

Questions, comments or complaints about the La Fuente Hollywood Treatment Centers privacy policies and procedures or about the collection, use or disclosure of personal information will be directed to the Privacy Officer.

The Privacy Officer will follow the procedures set out in the Client and Community Member Complaints policy in responding to, resolving and recording privacy-related complaints.

If the client is not satisfied with the response provided by the Privacy Officer, the client may contact the California Department of Consumer Affairs at 1-800-952-5210.

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