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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
6.0 DOCUMENTATION
• PHIPA Pamphlet
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