# Presentation: 066584

## HIPAA: The Privacy RuleImplementation in Job Corps

- Pat Jackson, RN
- Valerie Cherry, PhD
- Job Corps National Health and Wellness Conference
- April 26, 2007
- Denver, Colorado

## What is HIPAA?

- HIPAA stands for the Health Insurance Portability and Accountability Act. This is the result of the Kassenbaum-Kennedy bill that was signed into law in 1996. It started to be implemented in April 2003.
- Originally, it was designed to protect Americans, who were previously ill, from losing their health insurance when they changed residences or jobs. However, at present time, it does not seem that this goal has been achieved to any degree.
- It was also designed to streamline the health care system through the adoption of standards for transmitting electronic health care claims.
- From a practitioner point of view the heart of HIPAA regulations has to do with privacy, confidentiality, informed consents, billing and accessibility, storage and transmission of records.

## What is the HIPAA Privacy Rule?

- The rule identifies the groups or persons known as Covered Entities
- The HIPAA Privacy Rule creates national standards to address the use and disclosure  individuals’ health information
- It gives patients more control over their health information
- It sets boundaries on the use and release of protected  health information
- It establishes appropriate safeguards that health care providers and others must achieve to protect the privacy of health information

## Privacy Rule (continued)

- The rule identifies the groups or persons known as Covered Entities
- The rule regulates how these Covered Entities can use and disclose Protected Health Information (PHI)
- Job Corps’ Health and Wellness areas are considered Covered Entities under the rule

**Notes:**
Covered entities are health plans, health care providers who transmit health information in electronic form.  

## Privacy Rule (continued)

- Allows penalties be imposed on covered entities that violate the rule
- Allows for disclosure of PHI for public health, safety and law enforcement purposes
- Enables patients to make informed choices and to know how, when and to whom their PHI is used or disclosed

## State Confidentiality Laws

- If the state law is more stringent, then you must abide by that law
- Know the confidentiality laws in your state,
- Know the requirements of your licensing body regarding confidentiality
- Execute additional consent forms if necessary

## Requirements

- HIPAA Authorization is an eligibility requirement
- The Authorization describes how the student’s PHI will be used and disclosed except for uses related to TPO
- The complete Authorization (PRH  Change Notice 03-05, 11-7-03) must be filed in the Student’s health record (SHR)
- The HIPAA Notice must be signed during the first visit to HW and the complete form filed in the SHR
- Account for Disclosures
-  Designate a Privacy Officer and a Contact                                                Person

- I:	HIPAA and Code of Ethics
- II: Psychotherapy Notes, Records, and Students’ Access to Records

***Resources: ***
***GETTING READY FOR THE HIPAA PRIVACY RULE: A PRIMER FOR PSYCHOLOGISTS***
***by APA Practice Organization and the APA Insurance Trust***
***THE HIPAA COMPLIANCE KIT ***
***3rd Edition by Ofer Zur, Ph.D**** *

##  I: HIPAA and Code of Ethics

- 1. What is the relationship between HIPAA and the Code of Ethics?
*When a conflict exists between HIPAA and the CMHC’s professional association codes of ethics, the CMHC must state the commitment to codes of ethics but follow the HIPAA regulations, assuming that these regulations preempt state law.*

## Section II:  Psychotherapy Notes,  Records, and Students’ Access to Records

- 1. What is included in the psychotherapy notes?
*Include, but are not limited  a therapists’ own thoughts, feelings, or responses to  clients, Such as counter-transference details, sensitive information about other individuals in the patient's life. Hypotheses or speculations.*
- 2.What is excluded from the psychotherapy notes?
*In other words what belongs in the general health record is- medication prescription and monitoring; start and stop times of sessions (this is a new requirement.); modalities and frequency of treatment; results of clinical tests; summaries of: diagnosis; functional status; treatment plan; symptoms; prognosis; and progress.*
**Any information that is essential for treatment should not be part of the Psychotherapy Notes. Assume that no records are immune from disclosure. This also holds true for the Psychotherapy Notes. **

## Section II:  Psychotherapy Notes,  Records, and Students’ Access to Records

-  Does a Job Corps student have a  right to review their psychotherapy notes?
*No, unless there is a more stringent state law that allows patients access.*
- 2. Can a Job Corps student authorize disclosure of the psychotherapy notes?
*Yes, Job Corps Students can always sign an authorization to disclose the Psychotherapy Notes.  *

- 3. Can psychotherapy notes be disclosed without student authorization?
*When needed to avert a serious and imminent threat to the health or safety of a person or the public. *
*To a coroner or medical examiner for the purpose of identifying a deceased person or determining the cause of death. *
*When mandated by law.*

## Section II:  Psychotherapy Notes,  Records, and Students’ Access to Records

- The general record (Student Health Record Notes) may state:
*Brief Cognitive Behavioral therapy was implemented to treat student’s depression and anxiety. Cognitive restructuring was taught for problem solving techniques, to reduce anxiety, and increase effectiveness of coping style. *
- In contrast, the private Psychotherapy Notes chart might state:
*Student seems anxious and depressed as he deals with his childhood molestation. Cognitive restructuring originally met with some resistance. Additionally, it was a very difficult session as a number of transferential issues came up about student’s relationships to his molesting father and the carry over of these feeling towards the CMHC.** *

## Section II:  Psychotherapy Notes,  Records, and Students’ Access to Records

- 1.What rights do Job Corps students have to access their  health records?
*With limited exception, a student is allowed to inspect and obtain a copy of PHI in a designated record set. *

- 2.When do Job Corps students not have the right to access their records?
*A center may deny a student access if it is likely that the information will cause harm or endanger the student or another person.*
*Students have the right to have the denial reviewed by a licensed health care professional who did not participate in the original decision and the center must comply with the reviewer's decision**.*

## Section II:  Psychotherapy Notes,  Records, and Students’ Access to Records

- 1. What about minors’ records?
*There are a few exceptions to the right of parental access to minors’ records: *
*If a state law allows a minor to access mental health services without the consent of a parent. *
*When a court makes the determination. *
*When the law authorizes someone other than the parent to make health care decisions for the minor. *
*When the parent/guardian or person legally acting as the parent, consents to an agreement of confidentiality between the minor and the health care professional. *
*When records do not have to be disclosed, the minor may still voluntarily choose to involve a parent. In such a case, the minor maintains his or her rights to preserve the confidentiality of PHI.*

## The HIPAA “Block”

- HIPAA does not block the communication of information on a “need to know” basis on center
- Information can be shared in a way that does not breach confidentiality
- Information must be shared for the safety and security of students, staff and to protect the centers from liability

## What Can We Share?

- Question:  A student under 18 years of age has recently been placed on anti-depressants  with a black box warning.   What information could be shared?

**Notes:**
We may share with Residential Living staff information about medications, allergies, medical (including mental) conditions that may warrant emergency or other immediate care, accommodations or modifications requested, or infectious/contagious diseases 

## What can we share?

- Answer:  This student has been started on a medication and we would like for you to do the following:
- Observe and report and sleeping difficulties
- Observe and report any changes in behavior
- Observe and report any unusual behaviors
- Observe and report any self-harm behaviors or verbal threats
- May also share accommodations, if student has accommodation plan

**Notes:**
We may share with Residential Living staff information about medications, allergies, medical (including mental) conditions that may warrant emergency or other immediate care, accommodations or modifications requested, or infectious/contagious diseases 

## What can we share? (continued)

- Question:  A student reports being a _**heavy **_marijuana and/or alcohol user before entry and may suffer from withdrawal on center

**Notes:**
. We may share with Residential Living staff (including counselors), Trainee Employee Assistance Program (TEAP) specialists, and Mental Health staff (including mental health consultants) information about certain health conditions, as described below. This information may be shared for purposes of assisting you in meeting your own health needs while on Center. Information we may share includes the following: mental health information (excluding psychotherapy notes), including information about medications that may alter mental
functioning; information about pregnancies, diseases (including HIV), medication management, and illegal drug/alcohol use (including drug test results); information about accommodations or modifications you request, whether for a disability or for any other health condition; and oral health information, including treatment plan and appointments. We may share each piece of information only with particular staff members that need to know this information to assist you
or to avoid an emergency.
We may share with Residential Living staff information about medications, allergies, medical (including mental) conditions that may warrant emergency or other immediate care, accommodations or modifications requested, or infectious/contagious diseases. We
may share this information for the following purposes: assisting you with your medication
schedule or other health needs; protecting other students from infection or contagion; providing
you with an appropriate environment for allergy control, including, if necessary, appropriate
personal products; and ensuring that you receive requested accommodations or modifications in
your living quarters for any disability. In addition, if you have a condition for which medication
is prescribed for you, and you do not take that medication after you have been instructed to do
so, and your uncontrolled condition may result in an unwarranted risk to yourself or others, we
may share information about your condition and your failure to take your medication with
disciplinary staff, including the Center Standards Officer 

## What can we share? (continued)

- Answer: This student may have withdrawal symptoms from drug use, please observe student for anxiety, sweating, irritability, inability to sleep, physical tension, nausea, decreased appetite or mood, nausea, and refer to health and wellness.- Safety Concern

**Notes:**
. We may share with Residential Living staff (including counselors), Trainee Employee Assistance Program (TEAP) specialists, and Mental Health staff (including mental health consultants) information about certain health conditions, as described below. This information may be shared for purposes of assisting you in meeting your own health needs while on Center. Information we may share includes the following: mental health information (excluding psychotherapy notes), including information about medications that may alter mental
functioning; information about pregnancies, diseases (including HIV), medication management, and illegal drug/alcohol use (including drug test results); information about accommodations or modifications you request, whether for a disability or for any other health condition; and oral health information, including treatment plan and appointments. We may share each piece of information only with particular staff members that need to know this information to assist you
or to avoid an emergency.
We may share with Residential Living staff information about medications, allergies, medical (including mental) conditions that may warrant emergency or other immediate care, accommodations or modifications requested, or infectious/contagious diseases. We
may share this information for the following purposes: assisting you with your medication
schedule or other health needs; protecting other students from infection or contagion; providing
you with an appropriate environment for allergy control, including, if necessary, appropriate
personal products; and ensuring that you receive requested accommodations or modifications in
your living quarters for any disability. In addition, if you have a condition for which medication
is prescribed for you, and you do not take that medication after you have been instructed to do
so, and your uncontrolled condition may result in an unwarranted risk to yourself or others, we
may share information about your condition and your failure to take your medication with
disciplinary staff, including the Center Standards Officer 

## What can we share? (continued)

- Question:  A student is diagnosed with Depression.

**Notes:**
If student has trouble sleeping have them monitor what they drink or eat before bedtime (i.e.,caffeine)
Minimize naps during the day
Establish regular sleep and awake times
Suggest relaxation techniques

## What can we share? (continued)

- Answer:  There may not be a need to share anything, unless the student is experiencing current symptoms that require monitoring or has requested accommodations.

**Notes:**
If student has trouble sleeping have them monitor what they drink or eat before bedtime (i.e.,caffeine)
Minimize naps during the day
Establish regular sleep and awake times
Suggest relaxation techniques

## How can we share information?

- We can share information regarding behaviors to observe and support techniques by entering information:
- In CIS on the Case Notes page
- In CIS on the disability accommodation screen

## Who has a need to know?

- All staff who have direct contact with students have a need to know information regarding possible behaviors, recommended support for those behaviors and accommodations to prevent negative consequences

## Resources

- Health and Human Services: _[http://www.hhs.gov/ocr/hipaa](http://www.hhs.gov/ocr/hipaa)_
- Office of Civil Rights: _[http://www.hhs.gov/ocr/hipaa](http://www.hhs.gov/ocr/hipaa)__  _
- APAIT: _[http://www.apait.org](http://www.apait.org/)__ _
- Zuckerman’s page: _[http://www.hipaahelp.info](http://www.hipaahelp.info/)__ _
- _[http://www.addictionwithdrawl.com/alcohol.htm](http://www.addictionwithdrawl.com/alcohol.htm)__ _
- _[http://www.addictionwithdrawl.com/marijuana.htm](http://www.addictionwithdrawl.com/marijuana.htm)__  _
- _[http://www.hipaa.samhsa.gov/Part2footnotes.htm](http://www.hipaa.samhsa.gov/Part2footnotes.htm)__   _
- _[http://www.samhsa.gov](http://www.samhsa.gov/)__ _
- Publication
- The Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and the HIPAA Privacy Rule: Implications for Alcohol and Substance Abuse Programs, June 2004
- _http://www.ncbi.nlm,nih.gov.books__  _
- Publication
- SAMHSA/CSAT Treatment Improvement Protocols, Appendix K: Confidentiality,  Federal Laws and the Right to Confidentiality