WATERS & SIMS

LEGAL AND REGULATORY REQUIREMENTS

Contents

1.E.1 Legal and Regulatory Requirements 3

1.E.2 Response to Search Warrants, Subpoenas, Investigations and Other Legal Actions 5

1.E.3 Confidential Information Dissemination Policy 7

1.E.3.a Administrative Record Retention, Storage and Disposition 12

1.E.3.b Access to Client Records 15

1.E.3.c Maintaining Security of Client Protected Health Information 17

1.E.3.d Confidentiality of Client Record and Protected Health Information 19

1.E.3.d.1 Limits of Confidentiality 21

1.E.3.e Compliance with Applicable Laws concerning Clinical Records 22

1.E.3.f Timeframe for Client Record Documentation 23

1.E.1 LEGAL AND REGULATORY REQUIREMENTS

PURPOSE:

The leadership of Waters & Sims (WS) is firmly committed to ensuring that all levels of the organization comply with all applicable legal and regulatory requirements of any federal, state, county, or city entity. Such legal and regulatory requirements include:

rights of persons served,

confidentiality requirements,

reporting requirements,

contractual agreements,

licensing requirements,

corporate status,

employment practices,

mandatory drug testing,

privacy of persons served,

debt covenants,

and other legal and regulatory requirements that may present themselves in the course of day-to-day business operations.

Specific legal and regulatory requirements may relate to and/or include, but may not be limited to the following:

Department of Labor (DOL) regulations.

Occupational Safety and Health Administration (OSHA) regulations.

Internal Revenue Service (IRS) regulations.

Family Medical Leave Act.

Rehabilitation Act.

Age Discrimination in Employment Act.

Vietnam Era Veterans Readjustment Assistance Act.

Americans with Disabilities Act.

Titles VI and VII of the Civil Rights Act.

Fair Labor Standards Act.

Background checks and fingerprinting as required

All State Statutes that require the reporting of child or elder abuse or neglect.

CARF Standards.

As each employee’s job duties require, staff members are knowledgeable of applicable laws and regulatory requirements and are trained in complying with them.

As a CARF accredited organization, WS must provide reports from legal actions, regulatory agencies, or contractual relationships during each CARF Survey. In addition, during each CARF Survey, WS must provide a synopsis report that summarizes any of the following that may have occurred since the previous CARF Survey:

Litigation.

Allegations of wrongdoing (e.g., fraud, abuse, waste, etc.).

Malpractice.

Violations of codes of ethical conduct.

Finally, as per “Ongoing Communication Regarding Significant Events” in the WS Policies and Procedures for Site Surveys section of the CARF Standards Manual; it is a requirement that a synopsis report also be provided to CARF at the time any of the above may have occurred.

1.E.2 RESPONSE TO SEARCH WARRANTS, SUBPOENAS, INVESTIGATIONS AND OTHER LEGAL ACTIONS

PURPOSE:

This policy is established to advise all employees how to appropriately respond to an official search warrant and/or subpoena, investigations and other legal actions.

POLICY:

It is the policy of Waters & Sims (WS) that employees will not interfere in any way with the lawful execution of a search warrant and/or subpoena, investigations and other legal actions. WS is committed to full compliance and cooperation with any lawful subpoena or search warrant, investigations and other legal actions. Employees should be cooperative, courteous and professional when dealing with investigators or agents delivering these documents. No employee is to impede, in any way, efforts to deliver these documents.

PROCEDURES

SEARCH WARRANTS

Obtain and record the name of the lead agent and the agency they represent. Do not attempt to photocopy the credentials of an agent, as it is a violation of federal law.

The government agent in charge is required to provide a copy of the search warrant at the time of the search. If it is not provided, request a copy of the search warrant document. Carefully examine the search warrant. You may be able to call legal counsel and review it with them over the phone or fax it to them so they can review it with you. You are looking for the following information:

Are there any limitations on the areas or locations specified in the document to be searched?

Is the warrant being executed during the hours indicated on the document, e.g. daylight hours?

Has it been signed by a judge?

You may politely object if you believe there is any obvious problem with the warrant or if you believe the agents are searching anything or anywhere you feel is outside the scope of the warrant, but do not interfere should agents proceed and search. Note the fact of your objection and get this information to legal counsel.

Always remain present while the agents are conducting the search. In cases where agents are in multiple areas, assign staff to act as monitors to document what has been searched and what documents or objects have been seized. No employee should interfere with the search.

Request an “inventory list” of the documents and items seized by the agents. Try to make sure there is enough detail to be able to identify the documents and items taken by the agents. Also maintain a record of the areas searched and documents/items seized that you or assigned staff have observed.

Provide information to the agents to direct them to the information requested, but you do not need to submit to any form of questioning or interviewing.

The senior employee assigned to deal with search warrants or their designee should be responsible for responding to the agent’s questions.

Any questions by employees as to how to proceed, other than as described above, should be answered by legal counsel. The senior manager assigned should not advise employees of their legal rights nor direct them in any way to interfere with the process of the search.

SUBPOENAS

NO EMPLOYEE IS TO IMPEDE, IN ANY WAY, EFFORTS TO DELIVER A SUBPOENA.

Any subpoena, whether deliver in person or by mail, should be delivered immediately to the senior manager present at the site

If the subpoena is delivered in person:

The employee receiving it should get the name, title, and telephone number of the agent who serves the subpoena. This information must be given to the senior manager on duty along with the subpoena.

The employee receiving the subpoena or the senior manager should provide the agent/investigator with the information they need to deliver the subpoena to the appropriate or requested individual.

Do not volunteer information to an agent/investigator or submit to any form of questioning or interviewing.

The President/Director upon notice or receipt of the subpoena should be contacted, as soon as possible.

INVESTIGATIONS AND OTHER LEGAL ACTIONS

The employee, upon being given notice of an investigation or other legal action, should contact an on-site senior manager who should obtain background information of the pending investigation. Upon receiving this background information, the President/Director is to be contacted.

1.E.3 CONFIDENTIAL INFORMATION DISSEMINATION POLICY

POLICY:

It is the policy of Waters & Sims (WS) to ensure that all verbal and written information of persons served is released in a manner that protects the individual’s right to confidentiality. Information may not be released without the individual’s written permission, except as the law permits or requires. WS will make reasonable efforts to limit use, disclosure of, and requests for private health information to the minimum necessary to accomplish the intended purpose.

PROCEDURES:

1.Information may be released in written and/or verbal form. The release of information will occur upon receipt of an authorization determined as valid. Validity is determined by the presence of each of the following items:

A.The name of the person about whom information is to be released, including social security number.

B.The specific content of the information that is to be released.

C.The person to whom the information is to be released.

D.The signature of the person who is legally authorized to sign the release and the date on which the release is signed.

E.The expiration date of the authorization, not to exceed one year.

F.Information that defines how and when the authorization can be revoked.

2.Requests for Information:

A.All requests for information will be in writing.

B.Requests for information from an individual’s record will be answered within 30 days from the date of receipt. If the information cannot be provided within this period, the requester will be informed in writing of the reasons for the delay and the anticipated date the information will be available.

C.Requests for records that have been incorporated into WS's records from outside sources will not be released and the requestor will be encouraged to seek those records from their original source.

3.Release of Sensitive Information:

A.Information contained within the individual records may have a serious adverse effect on an individual’s mental or physical health if disclosed to the individual. Such information may contain materials requiring an explanation or interpretation to assist in its acceptance and/or assimilation in order to avoid an adverse impact on the individual’s health. To minimize the risk of a release of information adversely impacting a person served, the following guidelines will apply:

1)The HIPAA Compliance Officer will review all requests of individuals seeking direct access to their records. Information identified as potentially sensitive will be reviewed by the EXECUTIVE DIRECTOR. This review will occur within one working day of the referral.

2)All materials directly related to behavioral health treatment that includes a diagnosis, assessment, or interpretative data will be reviewed by the HIPAA Compliance Officer.

3)If after the professional review of the record, it is believed that disclosure of the information directly to the individual could have an adverse effect on that individual, arrangements will be made to disclose the information to a professional staff member selected by the individual. The staff member will discuss the information with the individual prior to the release.

4)Should it be determined by the professional staff member that after a careful and conscientious explanation of the information to the individual has been made, and it is the opinion that access to the information could be harmful, physical access will be denied. The justification for making the denial will be fully documented by the staff member and final concurrence will be made by the EXECUTIVE DIRECTOR. The individual will be advised of the denial, the reasons for the denial of the request, and advised of the right to file a grievance, should the individual disagree with the decision.

4.WS’s legal counsel and liability Insurance carrier will be notified and consulted when the release of information involves the following circumstances:

A.Any request for records that are to be used in a suit against the organization or in a prosecution against a person served.

B.For all subpoenas for records that were not accompanied by a written consent signed by the person served. President/Director will file a motion to quash with the Court which issued the subpoena. If that fails WS legal counsel will be consulted.

C.All requests for information which indicates a possible liability for the cost of care and services.

5.Information may be released without the consent of persons served under the following conditions:

A.For use by any WS employee who has a need for the information in the performance of their duties to ensure continuity of care.

B.To medical personnel who have a need for the information for the purpose of treating a condition which poses an immediate threat to the health of a person served.

C.To public health authorities related to infection with HIV when there is a written request that the information and there is a fine or penalty for failure to comply.

D.To recover or collect the costs of medical care from third party health care insurance carriers contracted with by the persons served and required by the health plan to be disclosed.

E.To Federal, State, or local government agencies or entities charged under applicable laws with the protection of public health and safety. In such cases, the information may be release with the consent of the individual whose records are being requested, or upon receipt of a written request from the head of the government entity. A request for release under these circumstances may be either a standing written requested based on reporting requirements, or a specific written request from the head of a law enforcement agency for a special law enforcement purpose. Standing requests must be updated in writing every year.

F.Disclosure as a result of a court order from a court of competent jurisdiction.

G.To the Medical Examiner, in conjunction with an investigation of a suspicious death.

H.To professional review organizations, in accordance with government contracts (Medicare/Medicaid).

I.Disclosure of information to a third party payer in a care cost recovery action will be limited to date of birth; social security number; payment history; and account number, unless the individual provides a written consent designating further information to be released.

6.An accounting record will be maintained on all records released by WS. It will include the date, nature and purpose of each disclosure, the name of the party to whom the disclosure is made. This accounting record will be maintained in the record from which the disclosure was made. In addition, a logbook will be maintained for all release of information for data reporting purposes.

7.Special consent is required to release records that contain information related to drug and alcohol addiction and abuse, and tests for, or infection with human immune virus. Any authorized disclosure from records containing information of this type will be limited to that information which is necessary for the purpose of the disclosure. Because of the special nature of this information, the release must be processed by the EXECUTIVE DIRECTOR to assure compliance with the special regulatory requirements.

8.The following types of communications do not constitute disclosure of information/records:

A.Communication of information between any WS employees who have a need for information in connection with their official duties.

B.Communications with law enforcement offices which are directly related to the person served committing or threatening to commit a crime on the organization’s property or against an employee of the organization.

C.Communication of information which does not provide an individual’s identifying information.

9.WS will protect the confidentiality of private health care information when transferring data electronically by adherence to the following guidelines:

A.All data sets containing individual names transferred on a diskette, e-mail or any other electronic medium, will be password encrypted.

B.The sending and receiving parties prior to transfer of the electronic data will negotiate passwords.

C.Passwords will be at least eight characters in length, contain both letters and numbers, and must not be commonly used words.

D.Passwords for encrypted files may not be mailed in the same shipping package as the encrypted file.

10.WS will adhere to the following guidelines when mailing confidential private health information:

A.Stamp all envelopes containing records as confidential.

B.Clearly indicate a particular office on the address where the envelope is to be delivered.

C.Whenever possible, include in the address the name of the staff member authorized to open the envelope.

D.All envelopes individually addressed will contain the following statement in the outside of the envelope: “TO BE OPENED BY ADDRESSEE ONLY”.

11.When faxing confidential information, the following guidelines will apply:

A.Confidential private health information will only be transmitted by fax when absolutely necessary or required by the requestor, and other traditional methods such as confidential mail is not possible to deliver the information.

B.All fax cover pages for confidential information will contain the following:

1)The name and program of the person to whom the fax is intended.

2)The name, program, and phone number of the person sending the fax.

3)The statement “Confidential Information” in a large bold font.

4)A statement that clearly identifies the accompanying material as confidential information that reads as follows: “The documents accompanying this facsimile transmission contain confidential information which is legally privileged. The information is intended only for the use of the recipient named above. If you have received this facsimile in error, please immediately notify us by telephone to arrange for return of the documents to us, and that you are hereby notified that and disclosure, copying, distribution or the taking of any action in reliance on the contents of this facsimile information is strictly prohibited.”

C.In situations where the information is not being regularly faxed to a common organization and individual, a phone call will be made to the person receiving the fax to verify the fax number and a follow-up call will be made to ensure receipt of the fax.

D.Fax transmissions will be restricted to people specifically authorized to transmit confidential information.

E.Fax machines will not be situated in common public areas.

F.Fax number lists will be current, accurate, and regularly checked.

G.All transmission records will be checked to detect possible transmission errors and retained for confirmation purposes.

H.Upon receipt of any confidential misdirected fax, the sender will be contacted and the information will be shredded.

12.Any information released verbally over the phone can only be done after verification of the caller’s identity through taking the phone number and making a call back prior to releasing the information.

13.All telephone calls from outside the organization that request confirmation of an individual being served by (Insert organization’s name), will be handled by repeating the following statement: “I can neither confirm or deny that the individual in question is receiving services or has ever received services without a written authorization from that individual.”

14.Any WS employee who knowingly and/or willfully violates provisions of this policy and procedures will face administrative disciplinary action that may result in termination of employment.

1.E.3.A ADMINISTRATIVE RECORD RETENTION, STORAGE AND DISPOSITION

PURPOSE:

To describe the Waters & Sims (WS) policy and procedure for retaining, storing, and disposing of administrative, employment, accounting, and billing records. The record may be in many forms including paper, and computer file. NOTE: This policy and procedure specifically excludes client or Client medical records.

POLICY:

WS will retain administrative, employment, accounting, and billing records for the period of time specified in the attached Records Retention, Storage, and Disposition Schedule, hereinafter referred to as “Schedule”. Records will be retained beyond the “Schedule” if the contents are relevant to the administration of any Internal Revenue Service Code or other regulatory body provision, audit, or litigation. Disposition will occur only after all pending matters are closed.

PROCEDURES:

1.Administrative Records retention, storage, and disposition are the responsibility of the President/Director or his/her designee. Administrative records are those records maintained by WS including Board documentation, Board meeting and committee meeting minutes, contracts, President/Director correspondence, corporate compliance issues and correspondence, and other items pertaining to the organization structure and operation of WS. Administrative records also include records maintained by the Director that pertain to the above. The records security procedure regarding disposition is memorialized in the WS Policy and Procedure Manual 1.E.3 Record Retention and Disposal.

A.The Director will by March 1 of each calendar year review administrative records. Through coordination with the President/Director, a determination will be made as to whether the record may be “material” to a potential or identified audit or legal action. If so, the record will be retained until all pending matters are closed. If the record is not subject to audit or legal action and the record has been retained for the period of time depicted on the “Schedule,” the record may be identified for disposition.

B.Records to be disposed will be containerized. Each container will be marked or labeled “for destruction”. Each container, so labeled, will be segregated from all other records and placed in a designated “holding” area awaiting final disposition.

2.Employment Records retention, storage, and disposition are the responsibility of the Director.

A.The Director will, by March 1 of each calendar year, review employment records. Through coordination with the President/Director, a determination will be made as to whether the record may be “material” to a potential or identified audit or legal action. If so, the record will be retained until all pending matters are closed. If the record is not subject to audit or legal action and the record relates to an individual who left the organization’s employ more than ten (10) years prior to the review date, the record may be identified and segregated for disposition.

B.Records to be disposed of will be containerized. Each container will be marked or labeled “for destruction”. Each container, so labeled, will be segregated from all other records and placed in a designated “holding” area awaiting final disposition.

3.Accounting Records retention, storage, and disposition is the responsibility of the Director. Generally, records for the current fiscal year and immediately preceding two fiscal years are maintained in the offices of the Director or staff. Records over three fiscal years old are stored in secure storage. Each box or cabinet containing stored records will be marked or labeled to identify contents and time period associated with the records.

A.The Director or designated representative will, by March 1 of each calendar year, review accounting records for retention or disposition. Through coordination with the President/Director, a determination will be made as to whether the record may be “material” to a potential or identified audit or legal action. If the record may be “material”, the record will be retained until all pending matters are closed. If the record is not subject to audit or legal action and the record has been retained for the period of time depicted on the “Schedule”, the record may be identified for disposition.

B.Records to be disposed of will be containerized. Each container will be marked or labeled “for destruction”. Each container, so labeled, will be segregated from all other records and placed in a designated “holding” area awaiting final disposition.

4.Billing Records retention, storage, and disposition is the responsibility of the Director. Generally, records for the current fiscal year and immediately preceding two fiscal years are maintained in the offices of the Supervisor or staff. Records over three fiscal years old are stored in the secure area. Records may be stored in boxes or storage cabinets. Each box, cabinet, or record will be marked or labeled to identify contents and time period associated with the record.

A.The Director or designated representative will, by March 1 of each calendar year, review billing records for retention or disposition. Through coordination with the President/Director, a determination will be made as to whether the record may be “material” to a potential or identified audit or legal action. If so, the record will be retained until all pending matters are closed. If the record is not subject to audit or legal action and the record has been retained for the period of time depicted on the “Schedule”, the record may be identified and segregated for disposition.

B.Records to be disposed of will be containerized. Each container will be marked or labeled “for destruction”. Each container, so labeled, will be segregated from all other records and placed in a designated “holding” area awaiting final disposition.

5.Records Disposal – The organization’s Director is responsible for acquiring the services of a reputable recycling/disposal company. The Director will estimate the amount of disposable material, contact one or more commercial recycling/shredding companies, determine rates and availability, and schedule the service to be performed. NOTE: Services are to be performed “on-site” unless there are approved procedures to safeguard confidentiality. Before services are performed, a “Certificate of Liability Insurance” shall be furnished to WS. After services are performed, a statement or an “Affidavit” confirming destruction” shall be furnished to WS.

1.E.3.B ACCESS TO CLIENT RECORDS

PURPOSE:

To define requirements relating to access to client records that assure compliance with applicable confidentiality laws and regulations.

POLICY:

It is the policy of Waters & Sims to allow the client access to their clinical records. In general, access will be coordinated through and in the presence of a WS clinical staff member for discussion, explanation and security of the clinical record.

PROCEDURE:

In accordance with Federal Confidentiality Regulations, 42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records, when not in use, confidential client records are to be maintained in locked quarters within the agency at all times.

Access to client records is governed by applicable sections of the Federal Confidentiality Regulations, 42 CFR Part 2 and 45 CFR Parts 160 and 164.

Disclosure of confidential client information, including access to client files, may occur among employees of the different departments comprising WS only to the extent necessary for said employees to perform the expected functions of their employment.

A Client File Log will be maintained. Information to be referenced on the Client File Log includes:

The date and time of day a client file was removed from the secured filing area,

Client name (as reflected on the client’s case file),

Name of the WS employee removing the client file,

The date and time of day a client file was returned to the secured file area,

Name of the WS employee returning the client file.

Any WS employee, student intern or other volunteer removing a client file from or returning a client file to the secured filing area will enter the proper information on the log.

All client files are to be properly stored in locked file cabinets at the end of each business day. The business office staff person responsible for such activity will check the Client File Log for that day and report any irregularities in activity or client files which have not been properly logged as returned to either the President/Director, as appropriate by site.

The President/Director is then responsible to investigate the cause of any such.

Federal Confidentiality Regulations allow access to confidential information, which may include access to client case files, to qualified persons for research, audit or program evaluation purposes. In such instances, the President/Director will designate a WS employee responsible to coordinate the efforts of outside entities qualified to conduct the research, audit or program evaluation. Before any such individual is allowed access to confidential information, including access to client case files, they will be required to sign a confidentiality agreement through which they acknowledge their understanding of and agreement to abide by the applicable confidentiality regulations.

Unless the person affiliated with an outside entity qualified to conduct the research, audit or program evaluation is personally known to the WS employee responsible to coordinate such efforts, the WS employee should request confirmation of that person’s identity through presentation of a valid picture identification card.

In accordance with the state law, a client may request information pertaining to their clinical record. Said request should be submitted in writing to the President/Director. Any information to be released shall include only elements detailed in the Clinical Records Policy.

Unless the client requesting copies of information from their client case file is personally known to the WS employee responsible to coordinate such efforts, the WS employee should request confirmation of that person’s identity through presentation of a valid picture identification card.

When releasing information from a client’s case file to the client or, in the case of minor clients, their legal guardian, only photocopies will be released. The original documents will remain in the possession of WS. In any such instance, the client will be required to sign a receipt acknowledging the information they are receiving at the time of the transaction. If the client is a minor, their legal guardian will also be required to sign the receipt.

1.E.3.C MAINTAINING SECURITY OF CLIENT PROTECTED HEALTH INFORMATION

POLICY:

Waters & Sims (WS) shall establish and maintain appropriate administrative, technical and physical safeguards to protect the privacy of protected health information from loss, tampering, defacement and unauthorized access. Safeguards shall be in place to protect information from any intentional or unintentional use or disclosure.

PROCEDURE:

1.All client service records shall be maintained

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