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1.0        PURPOSE 

The purpose of this policy is to communicate the provisions for protecting the Personal Health Information (PHI) of Residents. 

Protecting the privacy and the confidentiality of Resident information is important to all Team Members at the Steeves & Rozema Group.  Every Team Member of must abide by our commitment to privacy in the handling of personal and personal health information. 

The appropriate collection, use and disclosure of residents’ personal health information is fundamental to our day-to-day operations and to resident care.

2.0        SCOPE 

This policy applies to all S&R Nursing Homes who are required to collect PHI for the provision of healthcare and applicable services

3.0        DEFINITIONS  

Attorney for Personal Care: means an attorney under a power of attorney for personal care made in accordance with the Substitute Decisions Act, 1992, pursuant to the Personal Health Information Protection Act, 2004, S.O. 2004, c. 3 (hereinafter referred to as "PHIPA")

Attorney for Property: means an attorney under a continuing power of attorney for property made in accordance with the Substitute Decisions Act, 1992; pursuant to PHIPA.

Circle of Care: means a person or organization, whether a health information custodian or non-health information custodian within the meaning of PHIPA, that is directly or indirectly involved in the provision of care of the resident and the resident has provided express or implied consent to such provision of care by the person or organization.

Confidential Information: means all information, other than personal and personal health information, regarding a client, staff person, volunteer or the organization, that is seen, heard, obtained or observed.

Health Information Agent: in relation to a health information custodian, means a person that, with the authorization of the custodian, acts for or on behalf of the custodian in respect of personal health information for the purposes of the custodian, and not the agent's own purposes, whether or not the agent has the authority to bind the custodian, whether or not the agent is employed by the custodian and whether or not the agent is being remunerated; pursuant to PHIPA.

Health Information Custodian: (hereinafter referred to as "HIC") a person or organization who has custody or control of personal health information as a result of or in connection with performing the person's or organization's powers or duties or the work.

For the purposes of the policy the Health Information Custodian is each LTC Home and the registered staff is considered the health information agents.

Personal Health Information: means identifying information about a resident in oral or recorded form, if the information:

1.         Relates to the physical or mental health of the individual, including information that consists of the health history of the individual’s family

2.         Relates to the providing of health care to the individual, including the identification of a person as a provider of health care to the individual’s family

3.         Is a plan of service within the meaning of the Long-Term Care Act, 1994 for the individual,

4.         Relates to payments or eligibility for health care in respect of the individual

5.         Relates to the donation by the individual of any body part or bodily substance of the individual or is derived from the testing or examination of any such body part or bodily substance,

6.         Is the individual’s health number, or

7.         Identifies a resident’s substitute decision-maker, as defined by the Personal Health Information Protection Act (“PHIPA”).

Personal Information: means information about an identifiable individual, but does not include the name, title or business address or telephone number of an employee of an organization, as defined by the Personal Information Protection and Electronic Documents Act, 2000, c. 5 (hereinafter referred to as "PIPEDA").  Please see 7.5.4 Privacy Policy

4.0        REFERENCES

•           PHIPA (Personal Health Information Protection Act – November 1, 2004)

•           Long Term Care Homes Act, 2007 – O.Reg. 79/10

5.0        PROCEDURE (The 10 Principles of Privacy)

5.1        Accountability

We take our commitment to securing Resident Privacy very seriously.  Each Team Member associated with the Steeves & Rozema Group is responsible fro the personal information and personal health information group under his/her control.  Our Team Members are informed about the importance of privacy and receive information periodically to update them about our Privacy policies and related issues

5.2        Identifying Purposes (Collection and Use of Personal Health Information)

The purposes for the collection of confidential personal health information may include, but may not be limited to:

•           Making decisions about the types of services required by residents;

•           Providing direct resident care;

•           Communicating with other service providers and agents;

•           Monitoring the provision of services and evaluating the resident’s response to services provided;

•           Administering quality control and risk management programs;

•           Providing payment for health care, services or products;

•           Providing employee payroll, benefit and pension administration programs and other services; and

•           Meeting legal, and regulatory requirements

Before personal health information is collected, the persons collecting the information will explain to the Resident or Substitute Decision Maker (SDM) the purpose(s) for which the information is being collected. 

Personal health information collection shall be limited to that which is necessary for the purposes identified by the Home, or as otherwise permitted by legislation.

5.3        Consent

            You have the right to determine how your personal health information is used and disclosed.  For most health care purposes, your consent is implied as a result of your consent to treatment, however, in all circumstances express consent must be written. 

            PHIPA gives you the right to:

•           Grant permission or consent as to how your personal health information is collected, used and shared

•           Grants you the ability to gain access to your own health records

•           Grants you the ability to make corrections to your medical records

            PHIPA allows for two types of consent:

Implied Consent

Implied consent is when your health care provider collects your health information for the purpose of providing health care for you.  For example:  when your family physician refers you to another physician, he or she will assume that you give permission to share your health information with this physician, unless you specifically refuse. 

Express Consent

In certain situations, your health care provider is required to request your consent either orally, in writing or electronically, before sharing your personal health information.  For example:  before your physician may disclose your personal health information to someone who is not a health information custodian under PHIPA, such as your employer, your express consent must be obtained.

Express consent must be given by the Resident, SDM or Power of Attorney for Care, before a Home may disclose the personal health information of a Resident to an individual other than the Resident, SDM or Power of Attorney for Care.

Elements of Consent

Where policy or applicable legislation requires the consent of the Resident to collect, use or disclose of the Resident’s personal health information by the LTC Home, or on behalf of another Health Information Custodian, the consent must be:

•           A consent of the Resident

•           Must be knowledgeable (which means reasonable in the circumstances to believe that the individual knows the purposes of the collection, use or disclosure, and that the individual may give or withhold consent)

•           Must relate to the information; and

•           Must not be obtained through deception or coercion

            Who May Consent?

•           The Resident if the individual is capable of consenting to the collection, use and disclosure of their personal health information

•           The Substitute Decision Maker or Power of Attorney for Care

•           If the Resident is deceased, the executor or trustee of the Deceased’s estate

•           A Person whom and Act of Ontario or Canada authorizes or requires to act on behalf of the individual

            Capacity to Consent

A Resident is capable of consenting to the collections, use or disclosure of Personal Health Information in the following circumstances: 

•           The Resident is able to understand that the information is relevant for the purposes

•           The Resident is able to appreciate the reasonably foreseeable consequences of providing, not providing, withholding or withdrawing consent 


•           A Resident may be capable of consenting the collection, use or disclosure of Personal and Personal Health Information at one time, but incapable of consenting at another time, pursuant to PHIPA s. 21 (3)

•           A Resident is presumed to be capable of consenting to the collection, use or disclosure of personal and personal health information, and as a HIC, the Home staff or agents may presume a Resident has such unless the staff person or agent responsible for such collection, use or disclosure on behalf of the facility has reasonable grounds to believe that the individual is incapable of granting such consent, pursuant to this policy and PHIPA, s. 21 (4) and (5)


            Determination of Incapacity

A Health Information Custodian that determines the incapacity of a Resident to consent to the collection, use and disclosure of Personal Health Information under this Act shall do so in accordance with the requirements and restrictions, if any, that are prescribed in PHIPA


Withdrawal of Consent

A Resident or Resident’s Substitute Decision Maker may the consent at anytime whether the consent is express or implied, by providing notice to the Home

Withdrawal of consent will be permitted only where the withdrawal will not compromise the provision of care to the Resident, or such information is required to comply with the applicable legislation

5.4        Limiting Collection

We collect information by fair and lawful means and collect only that information which may be necessary for purposes related to the provision of your Medical Care.

5.5        Limiting Use, Disclosure and Retention

The information we request from you is used for the purposes defined.  We will seek your consent before using the information for purposes beyond the scope of this policy

Under no circumstances do we sell Resident information or other personal information to third parties.  There are some types of disclosure of your personal health information that may occur as part of this Practice fulfilling its routine obligations and/or practice management.  This includes consultants and suppliers to the Practice, on the understanding that they abide by our PHIPA and Privacy Policies, and only to the extent necessary to allow them to provide business services or support to the Steeves & Rozema Group

We will retain your information only for the time it is required for the purposes we describe and once your personal and personal health information is not longer required, it will be destroyed.  However, due to our on-going exposure to potential claims, some information is kept for a longer period.

Residents may be required to sign and date a Consent to Disclose PHI Form and pay a fee prior to release of information

5.6                    Openness and Accuracy

All S&R Nursing Homes do their best to ensure the accuracy of all Personal and Personal Health Information in its possession. However, we rely on you to disclose all material information and to inform us of any relevant changes.

A Resident or A resident’s SDM may, upon written request, view their Personal or Personal Health information to ensure the accuracy of the information, subject to applicable law.  If it is found that the Personal or Personal Health Information on file requires amendments, the HIC will Endeavour to amend the information accordingly upon receipt of documentary proof that the subject information is incorrect or missing.

5.7        Security Safeguards

We protect all forms of information collected from you or on your behalf (verbal, written and electronic) with appropriate safeguards and security measures.  Each S&R Nursing Home maintains personal information in a combination of paper and electronic files.  Recent paper records concerning individuals’ personal or personal health information are kept at each home and stored securely.

Access to personal health information will be authorized only for the physicians and Team Members associated with each S&R Nursing Home, and other agents who require access in the performance of their duties, and to those otherwise authorized by law.

We provide information to health care providers acting on your behalf, on the understanding that they are also bound by law and ethics to safeguard your privacy.  Other organizations and agents must agree to abide by our PHIPA and Privacy policies and may be asked to sign contracts to that effect.  We will give them only the information necessary to perform the services for which they are engaged, and will require that they not store, use or disclose the information for purposes other than to carry out those services

Our computer systems are password-secured and constructed in such a way that only authorized individuals can access secure systems and databases.

If you send us an e-mail message that includes personal or personal health information, such as your name included in the “address”, we will use that information to respond to your inquiry.  Please remember that e-mail is not necessarily secure against interception.  If you communication is very sensitive, you should not send it electronically unless the e-mail is encrypted or your browser indicates that the access is secure.

5.8        Challenging Compliance

We encourage you to contact us with any questions or concerns you might have about your privacy or our Privacy policies.  We will investigate and respond to your concerns about any aspect of our handling of your information.

In most cases, an issue is resolved simply by telling us about it and discussing it.  You can reach us at:

The Steeves & Rozema Group

Attention:  Privacy Officer

265 Front Street N., Suite 200

Sarnia, Ontario  N7T 7X1

Tel:  519-344-8829 ext. 316

Fax:  519-344-8518

Email:  privacyofficer@srgroup.ca

If, after contacting us, you feel that your concerns have not been addressed to your satisfaction, you have the right to complain to the Information and Privacy Commissioner/Ontario.  The Commissioner can be reached at:

2 Bloor Street East, Suite 1400

Toronto, ON

M4W 1A8

Email: info@ipc.on.ca

Toronto area: 416-326-3333

Toll Free: 1-800-387-0073

TDD/TTY: 416-325-7539



•           PHIPA Pamphlet




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