Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

CLIENT ORIENTATION CHECKLIST

Note: All appropriate information should be discussed with each individual

The information checked below has to be completed during the orientation of each individual.

 

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

 

Mission Statement

Comp Serv Health North Carolina mission is to provide therapeutic services that will improve the quality of life for individuals that have significant psychiatric functional limitations, and enabling them to become a more productive citizen. Comp Serv Health North Carolina ., provides the highest quality, outcome based, face to face intervention for adults, to enhance their quality of life by meeting and challenging the needs ofthe whole person: physical, mental, and social.

Our mission is to ensure that individuals participation in the design of and have access to culturally competent services and supports, as well as other assistance and opportunities that promote enhanced communities. Our staff supports people in discovering their mission in life, and based upon their changing discoveries; provide them with creative resources and opportunities for growth, encouraging them to embrace their own diversity and to welcome it in others. Furthermore, COMP SERV HEALTH NORTH CAROLINA is dedicated to promoting, through partnership and collaboration the way to service delivery systems and communities that afford each person with the opportunity to live a self-determined life in their own community.

Our Objectives:

1. To teach individuals the life skills they need to become more independent and productive citizens in their community.

2. To afford each person with the opportunity to live a self-determined life. To support clients in discovering and achieving their goals, encouraging them to embrace their own diversity and to welcome it in others.

3.To enhance client skills in symptom management, medication compliance, social interactions and successful community living.

4. To be a proactive force for our clients, to respond to today's society and it associated stressors.

5. To provide one-on-one intervention in a manner that meets standards of excellence.

My signature below indicates that I have read and understand the mission statement.

CONSENT FOR SERVICES, EMERGENCY TREATMENT, CONSENT FOR PHOTOGRAPH AND CLIENT CHOICE

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

I authorize Comp Serv Health North Carolina to provide IDD 1951i services and coordination of services. This may include individual and family sessions, case coordination and treatment planning. I understand the consent may be withdrawn at any time. 

In the case of a medical emergency, I hereby authorize Comp Serv Health North Carolina to obtain emergency medical care on my behalf. A medical emergency is defined as:

• Immediate services are required for the alleviation of pain, or
• Immediate diagnosis and treatment of unforeseeable medical conditions are required, if such condition would less to serious disability or death if not immediately diagnosed and treated.

I authorize Comp Serv Health North Carolina to take my photograph for the purposes of documenting activities and programs, and/or informing the public of our services. These photographs will in no way be used for individual or financial gain. 

I authorize Comp Serv Health North Carolina to email, text or fax information pertaining to my 1915i IDD services. I understand that Keys to Success Family and Developmental Services will use extreme caution to safe guard my personal information.

Client Choice: I have chosen Comp Serv Health North Carolina to provide the services to me that has been marked with a check. These services are listed below.

My signature below indicates that I have read and understand this consent/choice form. 

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

CONFIDENTIALITY

All Employees, volunteers, and students are required to abide by the following confidentially regulations for individual we service in our IDD services programs.

1. Statement of Guiding Principles

Agencies or individuals with access to or control over individual information, whether recorded or not, relating to a client who was received in connection with the performance of any function of the agency, shall take affirmative measures to keep client information confidential. Release or disclosure of client information to an individual shall be prohibited except under the following conditions:

A. When authorization for release has been given by the client.

B. When it has been determined by management that there is imminent danger to the health and safety of another or there is likelihood of commission of a crime; and

C.When in response to any oral order from a judge or written documentation by a judicial official which directs explicitly the release of client information; otherwise known as a court order.

My signature below indicates that I have read and understand the confidentiality policy.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Area Medicaid Provider Receipt

,have been informed that there are other Medicaid Providers in my area, and I have chosen Comp Serv Health North Carolina ., (COMP SERV HEALTH NORTH CAROLINA).

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Medicaid Appeal Process

 

Medicaid Member Appeals

Sometimes Trillium may not agree with a treatment decision your provider makes for your services. This decision is called an "adverse benefit determination." You will receive a letter from Trillium about this. Medicaid members have a right to tell us if they don't agree with this adverse benefit determination and can appeal the decision. You have 60 days from the date on your letter to ask for an appeal. When members do not agree with our appeal decision, they can ask the NC Office of Administrative Hearings for a State Fair Hearing within 120 days of the date of your appeal decision letter.

When you ask for an appeal, Trillium has 30 days to give you an answer. If you feel a delay will cause serious harm to your health or to your ability to attain, maintain, or regain your good health, you can ask for an "expedited" (faster) appeal. If you qualify, we will decide your appeal within 72 hours of your request. If you are denied an expedited request, you may file a formal Grievance with Trillium.

When you request an appeal, you can ask questions and give any updates (including new medical documents from your providers) that you think will help us approve your request. You may do that in person, in writing or by phone. Trillium's Appeals Coordinator can help answer any questions by calling 1-877-685-2415.

If you do not agree with Trillium's decision on your appeal, you have 120 calendar days from the date of your notice to submit an appeal to the Office of Administrative Hearings (OAH) by calling 1- 984-236-1860 or sending your request to:

Office of Administrative Hearings (OAH)

Attention: Clerk of Court

1711 New Hope Church Road Raleigh, NC 27609

Fax: 984-236-1850

For more information about the appeals process, please view the links below or the Member Handbook (Member Medicaid Direct, or Tailored Plan You can also call Member and Recipient Services at 1-877-685-2415.

• Member Appeals Brochure
• How to Make an Appeal

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

State-Funded Recipient Appeals

 

Sometimes Trillium may not agree with a request your provider makes regarding your state-funded services. You will receive a letter from Trillium notifying you of this decision. The letter will include information on the reason- for the decision and how you can appeal - if you don't agree. - State- funded recipients have the right to appeal these decisions. Trillium must receive the appeal in writing within 15 business days from the date of the letter. Trillium's Appeals Coordinator is available to help you with this process by calling 1-877-685-2415.

When you ask for an appeal, Trillium has 7 business days to give you an answer. When recipients do not agree with our appeal decisions, they can ask the Non-Medicaid Appeals Panel with the State Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH) for an appeal within 11 calendar days of the date of your decision letter.

Requests for appeals to the DMH/DD/SAS Panel may be faxed to 919-733-4962 or mailed to:

DMH/DD/SAS Hearing Office

c/o Customer Service and Community Rights

Mail Service Center 3001, Raleigh, NC 27699-3001

Customer Service and Community Rights Team: 984-236-5300

Do you need to file a complaint or grievance?

For Medicaid Members:

Contacting us with a grievance means that you are unhappy with Trillium, your provider, or your health services. Most problems like this can be solved right away. Whether we solve your problem right away or need to do some work, we will document your call, your problem, and our solution. We will inform you that we have received your grievance in writing. We will also send you a written notice when we have finished working on your grievance.

You can ask a family member, a friend, your provider, or a legal representative to help you with your grievance. If you need our help because of a hearing or vision impairment, if you need translation services, or help filling out any forms, we can help you.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

PARTICIPATION IN SERVICES

Comp Serv Health North Carolina provides the highest quality, outcome based, face to face intervention for adults and adolescents, to enhance their quality of life by meeting and challenging the needs of the whole person: physical, mental, and social. It is our mission to encourage individuals to participation in our services to enhance their quality of life and to achieve a higher level of stability. Below are the following required activities, while participating in our services.

REQUIRED ACTIVITIES

• The individual will participate in a face to face clinical assessment with a Licensed Professional to determine eligibility of our services.
• The individual will receive client centered and family focused treatment within the home environment.
• The individual will participate in the development and implementation of an PCP by a QP that will be fully completed within 30 days of the initiation of services and indicates the specific supports and services to be provided and the goals and objectives to be accomplished. The PCP should be cosigned by the individual.
• At a minimum, the individual will participate in services provided by Direct Support Staff Professional supervised by A Qualified Professional.
• A quarterly review of the PCP is required. The PCP must be rewritten at least annually.
• Minimally documentation and description of services through a daily log of the time as well as a weekly summary note is required.

My signature below indicates that I have read and understand the participation of services.

RELEASE FOR MUTUAL SHARING OF INFORMATION BETWEEN:

NAME/ADDRESS OF AGENCY, ORGANIZATION, OR INDIVIDUAL:

Comp Serv Health North Carolina

Mailing 6209 Oleander Office 202 Wilmington NC 28403

Physical: 3971 Business Hwy 17 Bolivia NC 28422

Specific Purpose: Post Discharge Evaluation This consent will end one year from the date the form is signed unless I indicate an earlier date or event here: 

 

The doctrine of informed consent has been explained to me and I understand the contents to be released and or shared,the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information.

I further understand that this consent may be revoked at any time except to the extent that action based on this consenthas been taken. Revocation must be made directly to the client Record Service serving the facility you are active in. Ihereby acknowledge that this consent is truly voluntary and is valid until such request is fulfilled.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

EMERGENCY PREPAREDNESS AND RESPONSE PLAN

Disaster Plan For Staff / Emergency Procedures For On-Call Staff

This plan ensures prompt, effective intervention in the event of an emergency.

A. In the event of natural disaster, severe weather, fire, flooding, workplace violence, terrorism, missing persons, severe injuries or any other emergency that would preclude staff from delivering effective service, the following procedures shall be adhered to:

• The Director will contact counselors, referring worker and or other authorized individuals regarding this course of action.
• Each assigned counselor will be responsible for contacting service recipients, and their family members or guardians regarding the course of action within 30 minutes of the acknowledgement of the plan.
• The Director will contact license authority within twenty four hours of an emergency.
• The agency will provide training to staff regarding agency protocol in the event of an emergency upon hiring and annually thereafter.

B.  The following Emergency Preparedness numbers will be posted in Comp Serv Health North Carolina ., offices and employees are required to maintain a copy of these telephone numbers and have them readily available when providing direct services to clients and their families:

1) Fire

2) Police

3) Poison Control

4) Administrator

5) Nearest Hospital,

6) Ambulance Services

7) Rescue Squad and

8) Other trained medical personnel

 

C.All employees shall discuss with the client's emergency preparedness plans as outlined by the agency during their first session with the client and their family.

D.Severe Weather: In the case that an employee is at the home of a client during the predictions of a severe weather warning, the employee shall discontinue the session and depart the home.

Warning: A warning is issued when the National Weather Service (NWS) has sighted by a trained spotter or by radar a severe storm or tornado. Persons in the warning area should take cover immediately.

Should severe weather occur, fast and clear thinking is necessary to save lives.

Lightning: Stay away from windows. Unplug all electrical appliances.

High Winds and Hail: Stay away from windows. Large hailstones can shatter a window easily. High winds can bring branches flying through windows with incredible force.

In the case that an employee is on a therapeutic outing during the predications of a severe weather warning, the employee shall return the client home immediately to the custody of his parent or legal guardian.

Severe Thunder Storm: A severe thunderstorm is classified as a storm with very high winds, excessive lightning and heavy rain. Hail very often occurs during a severe storm. Tornadoes are not most common insevere storms. Pay close attention to the cloud surfaces, watching for churning and twisting clouds. In the casethat an employee is found in the middle of severe weather with a client, the employee shall immediately seekappropriate safety. The employee shall notify the Program Director immediately and discuss the plan of action.The Program Director will notify the guardian immediately after identification of the plan and shall keep theguardian informed every 15 minutes. The employee shall maintain contact with the Program Director every 10 minutes.

Missing Clients: In the case that a client becomes missing while under the supervision of an employee, theemployee shall:

Search for the client for at least 30 minutes and no more than 1 hour in the surrounding environment where clientwas last seen.

• During the initial search, the employee shall notify the Program Director.
• The Program Director will notify the legal guardian of the situation within the first 30 minutes of theclient being identified as missing.
• If the client is not found within 1 hour, the employee shall notify the local police and cooperate with their investigation.

In the case the client is located; the employee shall immediately inform the Program Director who will inform theguardian. In addition, the employee shall return the client home and process with the guardian the situation andestablish appropriate consequences if warranted.

The employee shall complete the Incident Report form within 24 hours and document the same in the client’s progress notes.

Emergency Procedures For On-Call Staff:

A. Try to locate staff if on duty to aid with emergency procedures.

B. Follow written procedures in Policies and procedures

1. If a genuine emergency, call:

2. Call Director. Leave message on answering machine and indicate that you either talked directly to otheradministration or if you simply left a message.

3. Administration will call you back and help out as needed.

C. Call contract agency and alert to emergency

D. Remain calm. Does the situation require immediate on-site care or can it be handled by phone? Proceed accordingly.

E. Set plan for the emergency. Either go to site or locate support staff to go immediately.

F. Re-state plan of action with persons involved.

G. Fill out Incident Report

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Comp Serv Health North Carolina., staff does not administer medications to clients.

Illnesses and Accidents

1.In case of an accident or sudden adverse change in a consumer's physical condition/adjustment, a program shall obtain needed care immediately and notify the responsible relative and the person or agency responsible for placement.

2. An occurrence of a reportable communicable disease as defined by the laws of this State or the rules implementing such laws shall be reported immediately to the local health department, the department of social services and the contract agency.

3.Immediate investigation of the cause of an accident or incident involving a consumer, employee or visitor shall be initiated by Comp Serv Health North Carolina., administration and an appropriate accident/incident report to be completed and maintained. Within 24 hours, serious accident requiring medical attention shall be reported to the Director for review.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

GRIEVANCE PROCEDURE

POLICY:

Comp Serv Health North Carolina., is committed to treating clients that it serves with dignity and respect. Eachindividual has the freedom to voice his/her opinions without adverse effect on services. We would like the opportunityto resolve complaints and to propose a solution. The Clinical Director/Supervisor is responsible for organizing andmanaging the grievance process. Although it is anticipated that most complaints/grievances can be resolved by the staff,supervisor, if the issue is not resolved at the first level, there are provisions for additional involvement in the case.

Definitions:

Grievant: The Grievant is the person lodging the grievance or the complaint.

Respondent: The Respondent is the person(s) against whom a grievance is lodged.

Grievance Coordinator: The Grievance Coordinator is the individual to whom a formal, written grievance must besubmitted. The Grievance Coordinator is to assist the parties in seeking a satisfactory resolution of the issues and not todetermine who is “right” or “wrong”. The Grievance Coordinator will remain neutral throughout the proceedings and willserve primarily as a facilitator.

PROCEDURE: Grievance Process

A. Step One (Initial Discussion)

• The grievance must be brought to the attention of the parties involved. When an individual has a complaint,the staff involved shall attempt to resolve the issue informally by discussing the problem with the grievant,within 24 hours. In instances where the Grievant feels uncomfortable speaking to the respondent or animmediate supervisor the Grievant can contact the Grievance Coordinator.

B. Step Two (Meeting with Supervisor)

• If the Grievance is not resolved in Step One then the Supervisor should contact the grievant at 888 7513730 to discuss his/her concerns. This step should be undertaken within five business days of thecomplaint. If the grievant is still dissatisfied with the decision, then he or she must be given the opportunityto file a written grievance. It shall be explained at that time what are his or her options if there arecomplaints to register. If the Grievance involves the supervisor, then the next level of supervisor should contact the grievant. If there is any question that an individual’s rights may have been violated, theinvolved staff must fill out an Incident Report and submit it immediately to the Program Director within 24-72 hours depending on the grievance and/or right violation.

C. Step Three (Mediation/Resolution):

• Upon notification/receipt of a written grievance, the complaint will be reviewed by the ExecutiveDirector/Supervisor. After all facts have been compiled and formulated, a meeting will be held to resolvethe grievance and/or complaint. Appropriate actions will be taken as a result of the meeting to resolve thecomplaint or grievance. The grievant may choose an individual or group to serve as his or her representative.  (The grievant must be ensured that he or she is protected from any form of restraint,coercion, reprisal, discrimination or intimidation). To the extent possible, Comp Serv Health North Carolina., shall resolve all complaints within ten business days following issuance of the complaint.

D. Step Four (Non- Resolution):

• Should the grievant still not be satisfied with the resolution, the names and addresses of the Area Program Rights Representative, Legal aid and/or other advocacy groups will be provided to the grievant as a furthercourse of redress.

My signature below indicates that I have read and understand the grievance procedure.

 

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

SERVICE GUIDELINES

Comp Serv Health North Carolina provides 1915 i IDD services to persons with intellectual developmentaldisabilities. We provide child-centered and family-focused treatment within the home and communityenvironment. Comp Serv Health North Carolina., coordinates assessment and evaluation to confirm diagnosisthe clinical and functional deficits of the child and family, as well as their strengths and abilities, and utilizesevidenced-based practices to provide insight and behavioral change.

SUPPORTS PROVIDED

1915(i) Community Living and Supports (CLS) is an individualized or group service that enablesthe beneficiary to live successfully in their own home, the home of their family or naturalsupports and be an active member of their community. A paraprofessional assists the beneficiaryto learn new skills and supports the beneficiary in activities that are individualized and alignedwith the beneficiary’s preferences.

The intended outcome of the service is to increase or maintain the beneficiary’s life skills orprovide the supervision needed to empower the beneficiary to live in the primary privateresidence of their family or natural supports or in their private primary residency. The goal is tomaximize self-sufficiency, increase self- determination and enhance the beneficiary’s opportunityto have full membership in their community. Community Living and Support enables the beneficiary to learn new skills, practice or improve existing skills, provide supervision andassistance to complete an activity to their level of independence.

Community Living and Supports provides the beneficiary the following:

a. : the ability to gain skills in:

1. independent living;

2. community living;

3. self-care; and

4. self-determination.

b.: Support or assistance in or with:

1. monitoring a health condition;

2. monitoring nutrition;

3. monitoring of a physical condition;

4. incidental supervision;

5. daily living skills;

6. community participation; or

7. interpersonal skills

ELIGIBILITY CRITERIA

Medicaid shall cover Community Living and Supports when ALL following criteria are met: a. The beneficiary is ages 3 or above; AND b. One of the following is met: 1. I/DD as defined currently insection 1.1; or 2. A DSM 5 (or later) diagnosis of ID, Unspecified ID, or ASD; or 3. A geneticallydiagnosed syndrome that is typically associated with I/DD (e.g., Down Syndrome); or

and c. The beneficiary can benefit from skill acquisition, monitoring and/or supervision (beyond what is expected of natural supports) in one or more areas listed below: 1. interpersonal, independent living, community living, self-care, and self-determination; or 2. a health condition, nutrition or physicalcondition, incidental supervision, daily living skills, community participation, or interpersonal interactions.

Admission Criteria a. A standardized independent evaluation completed by the Division of Health Benefits to determine beneficiary eligibility for 1915(i) benefit based on the needs-based criteria; and b. An Independent Assessment completed by a tailored care manager or the Cherokee Indian Hospital Authority (CHIA) for Tribal members that indicates the beneficiary would benefit from Community Living and Support

LIMITATIONS

Medicaid Additional Criteria Not Covered Transportation to and from the school setting is not covered underCommunity Living and Supports and is the responsibility of the school system. a. Community Living andSupports provide only transportation to and from the beneficiary’s primary private residence or anycommunity location where the beneficiary is receiving services. b. Incidental housekeeping and mealpreparation for other household members is not covered under Community Living and Supports. c. Abeneficiary who receives 1915(i) Community Living and Supports shall not receive services through a1915(c) waiver. d. Relatives who live in the same primary private residence, as a beneficiary who is under 18years old, cannot provide Community Living and Supports. e. Relatives who live in the same primaryresidence as beneficiary, who is over 18 years old, can provide Community Living and Supports if the relativemeets the required staffing qualifications.

CONTINUED STAY CRITERIA

Medicaid shall cover continued stay if: a. The beneficiary continues to meet Admission Criteria for service.Refer to Subsection 3.2.4. b. The beneficiary requires assistance with at least one functional deficit andwho can benefit from either skill acquisition in at least one area from the following: interpersonal,independent living, community living, selfcare, and self-determination or assistance in monitoring a healthcondition, nutrition or physical condition, incidental supervision, daily living skills, communityparticipation, and interpersonal skills

DISCHARGE CRITERIA

The beneficiary meets the criteria for discharge if any ONE of the following applies: a. The beneficiary nolonger meets Admission Criteria for service. Refer to Subsection 3.2.4; b. The beneficiary no longer requiresassistance with at least one functional deficit; c. The beneficiary has requested discharge; or d. The beneficiary is enrolled in an NC Medicaid Home and Community Based Services Waiver

SERVICE UNITS AND MAXIMUM SERVICE LIMITATIONS

Community Living and Supports (community only–28 hours per week–T2012 U4

Community Living and Support group                                             T2013 HQ U4

Community Living and Supports (relative as provider)                      T2012 GC U4

Community Living and Support individuals EVV                                T2013 TF U4

 

A beneficiary who is in school is eligible for up to 15 hours (or 60 units) a week on weeks school is insession and up to 28 hours (or 112 units) a week on weeks school is not in session. Community Living andSupports may be authorized up to 28 hours or 112 units a week for a beneficiary 22 years of age and older. Ifa beneficiary is age 18 or older and has graduated (graduation with a degree indicating a standard course ofstudy or an occupational course of study, a GED, a Certificate of Completion or proof of the exhaustion oftheir educational course of study) then they are eligible for over 22 limit

For Community Living and Supports Group, group size cannot exceed three (3) beneficiaries to one (1) staff.The group size may be smaller if the staff is not able to maintain health and safety at all times, for allbeneficiaries in the group.

 

My signature below indicates that I have read and understand the Service Guidelines.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

HOURS & DAYS OF OPERATION

Our services are designed to assist the individual in acquiring mental health/substance abuse recovery skillsnecessary to successfully address his/her mental health, emotional and behavioral needs. 1915 i IDD services,Counseling includes providing “first responder” crisis response on a 24/7/365 basis to enrolled recipientsexperiencing a crisis situation.

Office Hours: Monday through Friday 9:00am to 5:00pm

Availability of After-Hours Service

1915 i IDD services includes providing “first responder” crisis response on a 24/7/365 basis to enrolledrecipients experiencing a crisis situation. We encourage the individuals in our services to contact the assignedQualified Mental Health Professional in an event of a crisis situation after hours. If the QP is not available,call the crisis hot line for your local area, listed below:

For 24-Hour Consultation

 

My signature below indicates that I have read and understand the Hours and days of Operation.

 

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Health Insurance Portability and Accountability Act (HIPAA)

Federal Standards for Privacy of Individually Identifiable Health Information Under the Health Insurance Portability and Accountability Act (HIPAA Comp Serv Health North Carolina is required by law to maintain the privacy of protected health information.

This privacy rules creates national standards to protect individuals' medical records and other personal health

• It gives individuals more control over their health information.
• It sets boundaries on the use and release of health records.
• It establishes appropriate safeguards that providers must achieve to protect the privacy of health information.
• It holds violators accountable, with civil and criminal penalties that can be imposed of they violate an individual's privacy rights.
• It strikes a balance when public responsibility requires disclosure of some forms of data-for example, to protect public health.

Information protected: All medical records and other identifiable health information used or disclosed by COMP SERV HEALTH NORTH CAROLINA LLC in any form, whether electronically, on paper, or orally, are covered by these standards. This includes, but is not limited to: name, address, phone number, social security number, Medicaid ID number, diagnosis, and service dates.

These standards give individuals significant rights to understand and control how their health information is used.

1. Right to Notice - an individual has a right to adequate notice of the uses and disclosures of protected health information that may be made by COMP SERV HEALTH NORTH CAROLINA , LLC of the individual's rights, and. COMP SERV HEALTH NORTH CAROLINA LLC's legal duties with respect to protected information.

2.Right of Access and Review - an individual has a right of access to inspect and obtain a copy of protected health information in their record for as long as the information is maintained in that record, with certain specific exceptions.

3. Right to Amend - an individual has the right to have COMP SERV HEALTH NORTH CAROLINA, LLC amend protected health information or a record about the individual for as long as the information is maintained in that record.

Process:

You may ask us to amend your health information if you believe that it is incorrect or incomplete. To request an amendment, you must submit a written document to our Privacy Coordinator at the local office and tell us why you believe the information is incorrect or inaccurate. We will deny your request if:

(a) Your request is not in writing or does not include a reason to support the request.

(b) The information was not created by us, unless the entity that created the health information is no longer available to make the amendment;

(c) The information is not part of the health information we maintain to make decisions about your care; 

(d) The information is not part of the health information that you would be permitted to inspect or copy;or

(e) The information is accurate and complete.

If COMP SERV HEALTH NORTH CAROLINA , LLC denies your request to amend, we will send you awritten notice of the denial stating the basis for the denial and offering you the opportunity to provide awritten statement disagreeing with the denial. If you do not wish to prepare a written statement ofdisagreement, you may ask that the requested amendment and our denial be attached to all future disclosuresof the health information that is the subject of your request.

If you choose to submit a written statement of disagreement, we have the right to prepare a written rebuttal toyour statement of disagreement. In this case, we will attach the written request and the rebuttal (as well as theoriginal request and denial) to all future disclosures of the health information that is the subject of your request.

(4) Right to request Restrictions of Uses and Disclosures –COMP SERV HEALTH NORTH CAROLINA , LLC must permit an individual to request that information about them be restrictedexcept for specific information that would not be needed for emergency treatment.

(5) Right to Accounting of Disclosures – an individual has a right to receive an accounting ofdisclosure of protected health information made by COMP SERV HEALTH NORTH CAROLINA ,LLC. This is accomplished by completion of the Accounting of Disclosures form each time adisclosure is made.

(6) Right to file a Complaint – an individual may file a complaint with COMP SERV HEALTHNORTH CAROLINA , LLC or with Secretary of the U.S. Department of Health and Human Servicesif a person believes COMP SERV HEALTH NORTH CAROLINA , LLC is not complying with theFederal Standards for Privacy.

(7) Right to request an Alternative Method of Contact – an individual has the right to be contacted ata different location or by a different method. For Example, you may prefer to have all writteninformation mailed to your work address rather than your home address. COMP SERV HEALTH NORTH CAROLINA , LLC will agree to any reasonable request for alternative methods of contact.If you would like to request an alternative method of contact, you must provide us with a request inwriting. You may complete an Alternative Contact Request Form. Alternative Contact Request Forms are available from our Privacy Officer or your assigned clinician.

Only designated individuals have the authority to access, amend, release, or disclose information.Consult with your Program Director or Supervisor to obtain the name(s) of the designated employees.

You are responsible for protecting and securing confidential information in your possession. Detailed information on COMP SERV HEALTH NORTH CAROLINA , LLC confidentiality policies may be found inthe Record Policy and Procedures implementing regulations (42 CFR Part 146) prohibit the release ordisclosure of information without an individual’s consent.

• Place information in drawers and/or file folder. Do not leave in view on desk
• Lock files or office when unattended.
• Turn computer screens away from view of others when working on confidential information. Closefiles containing confidential information when leaving your office or work area.
• Remove information from printers and copiers immediately.
• Limit the faxing of confidential information.
• Do not email confidential information over unsecured networks.
• Do not store information on the individuals we support on hard drives of home computers. Use a diskette or if authorized, log on to the network. Keep diskettes secured and locked.
• Do not store information on the individuals we support on lap top computers. Use a diskette, or ifauthorized, log on to the network. Keep diskettes secured and locked. Transport the disks separatelyfrom the computer case.
• Employees providing community services should use only the first name or initials on service records and datasheets until submitted for filing. These should be kept from view and stored in the trunk or a locked compartment.

Your Program Director or Supervisor will train you on the specific policies and procedures regarding confidentiality and protected information as necessary and appropriate for you to perform the functions ofyour position.

The officer for Comp Serv Health North Carolina ., is the Chief Financial Officer located at 6209 Oleander Office 202 Wilmington NC 28403 888 751 3730. The Privacy Contact Person is the Director of Quality Operations and Management located at 6209 Oleander Office 202 Wilmington NC 28403 888 751 3730

 

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington Telephone 888 751 3730

Acknowledgement of Receipt of Privacy Practices / HIPPA Policies

I have received a copy of the Notice of Privacy Practices and HIPPA Policy for the above-named agency.

For Office Use Only

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Emergency Medical Information

PERSONAL PHYSICIAN:

RELATIVE OR OTHER PERSON TO BE NOTIFIED IN EMERGENCY:

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Authorization to Transport

has permission to be transported to and from activities by Comp Serv Health North Carolina staff members. 

This authorization is in effect for the time that services are provided by Comp Serv Health North Carolina. When under the supervision of COMP SERV HEALTH NORTH CAROLINA staff will exercise our best judgement and observe normal precautions. Nevertheless, unforeseeable situations may arise that would require your child to be treated medically on an emergency basis. In such a case, we will make every possible attempt to reach you before making any decisions. However, if we are unable to reach you, we are asking for your permission to seek medical care on behalf of the above-named child.

I agree to release Comp Serv Health North Carolina from liability from an incident or when providing emergency medical treatment becomes necessary for the welfare of the above-named child.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Program Rules

During the provision of services., (COMP SERV HEALTH NORTH CAROLINA) client(s) shall:

1. Participate fully and honestly in treatment and services activities;

2. Remain available for appointments with their COMP SERV HEALTH NORTH Carolina's counselor(s) and mentor(s); DSP staff

3. Refrain from the use of any abusive vulgar, obscene or demeaning language;

4. Refrain from any harassing, aggressive, threatening or assaultive conduct towards others; and

5. Respect the property right of others.

A COMP SERV HEALTH NORTH CAROLINA staff member has explained the foregoing rules to me, and I have read and understand them. I understand that, if a client engages in repeated or serious violations of these rules, the client may be discharged from the COMP SERV HEALTH NORTH CAROLINA Program.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Notice of Client Rights

It is your right to:

1) Retain your legal rights as provided by state and federal law.

2) Receive prompt evaluation and treatment or training about which you are informed insofar as you are capable of understanding.

3) Be treated with dignity as a human being and be free from all forms of abuse.

4)Not be the subject of experimental or investigational research without your prior written and informed consent or that of your authorized representative.

5) Be afforded an opportunity to have access to consultation with a private physician at your own expense, and in the case of hazardous treatment or irreversible surgical procedures have, upon request, an impartial review prior to implementation, except in case of emergency procedures required for the preservation of your health.

6) Be treated under the last restrictive conditions consistent with your condition and not be subjected to unnecessary physical restraint and isolation.

7) Be allowed to send and receive sealed letter mail.

8)Have access to your medical and mental records and be assured of their confidentiality, but notwithstanding other provisions of the law such a right shall be limited to access consistent with your condition and sound therapeutic treatment.

9) Have the right to an impartial review of violations of the rights assured under this section and the right to access to legal counsel.

10) Be afforded appropriate opportunities, consistent with your capabilities and capacity to participate in the development and implementation of your individualized services plan.

Please note that you are also entitled to a copy of the document entitled "How to File a Human Rights Complaint."

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Notice of Client Rights 

 

Client Copy

It is your right to:

1. Retain your legal rights as provided by state and federal law.
2. Receive prompt evaluation and treatment or training about which you are informed insofar as you are capable of understanding.
3. Be treated with dignity as a human being and be free from all forms of abuse.
4. Not be the subject of experimental or investigational research without your prior written and informed consent or that of your authorized representative.
5. Be afforded an opportunity to have access to consultation with a private physician at your own expense, and in the case of hazardous treatment or irreversible surgical procedures have, upon request, an impartial review prior to implementation, except in case of emergency procedures required for the preservation of your health.
6. Be treated under the last restrictive conditions consistent with your condition and not be subjected to unnecessary physical restraint and isolation.
7. Be allowed to send and receive sealed letter mail.
8. Have access to your medical and mental records and be assured of their confidentiality, but notwithstanding other provisions of the law such a right shall be limited to access consistent with your condition and sound therapeutic treatment.
9. Have the right to an impartial review of violations of the rights assured under this section and the right to access to legal counsel.
10. Be afforded appropriate opportunities, consistent with your capabilities and capacity to participate in the development and implementation of your individualized services plan.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

IIH Authorization for Release of Information

I authorize the following organization to release information as stated below from the client confidential record

As the person signing this authorization, I acknowledge that I am giving my permission to the above-named person/class of persons to disclose and use protected health information. I further acknowledge that:

• I may refuse to sign this authorization.

• The above‐named person/class of persons cannot condition the provision of treatment to me on my signing thisauthorization.

• The original or a copy of this authorization shall be included with my original medical records.

• I have the right to revoke this authorization in writing at any time, but is not retroactive to information already released inaccordance to the authorization.

• There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipientand, therefore, no longer protected by the provision of the HIPAA Privacy Rule. If this information is being disclosed fromrecords protected by the Federal Substance Abuse Confidentiality Rules (42 CFR part 2), the Federal rules prohibit the recipientfrom making any further disclosure of this information unless further disclosure is expressly permitted by your writtenauthorization or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or otherinformation is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate orprosecute any alcohol or drug abuse person.

 

The consumer understands the terms of the consent and his or her right to obtain information on the disclosures.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Authorization for Release of Information

For the purposes of assessment and service coordination, the undersigned hereby authorizes Keys to Success Family and Developmental Services, LLC., (COMP SERV HEALTH NORTH CAROLINA) to exchange information with:

unless revoked by the undersigned. 

This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug patient.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Authorization for Release of Information

I authorize the following organization to release information as stated below from the client confidential record

As the person signing this authorization, I acknowledge that I am giving my permission to the above‐named person/class of persons to disclose and use protected health information. I further acknowledge that:

• I may refuse to sign this authorization.
• The above‐named person/class of persons cannot condition the provision of treatment to me on my signing this authorization.
• The original or a copy of this authorization shall be included with my original medical records.
• I have the right to revoke this authorization in writing at any time, but is not retroactive to information already released inaccordance to the authorization.
• There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipientand, therefore, no longer protected by the provision of the HIPAA Privacy Rule. If this information is being disclosed fromrecords protected by the Federal Substance Abuse Confidentiality Rules (42 CFR part 2), the Federal rules prohibit the recipientfrom making any further disclosure of this information unless further disclosure is expressly permitted by your writtenauthorization or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or otherinformation is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate orprosecute any alcohol or drug abuse person.

The consumer understands the terms of the consent and his or her right to obtain information on the disclosures.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia 6

209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Authorization for Release of Information

I authorize the following organization to release information as stated below from the client confidential record

As the person signing this authorization, I acknowledge that I am giving my permission to the above‐named person/class of persons to disclose and use protected health information. I further acknowledge that:

• I may refuse to sign this authorization.
• The above‐named person/class of persons cannot condition the provision of treatment to me on my signing this authorization.
• The original or a copy of this authorization shall be included with my original medical records.
• I have the right to revoke this authorization in writing at any time, but is not retroactive to information already released inaccordance to the authorization.
• There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipientand, therefore, no longer protected by the provision of the HIPAA Privacy Rule. If this information is being disclosed from records protected by the Federal Substance Abuse Confidentiality Rules (42 CFR part 2), the Federal rules prohibit the recipient from making any further disclosure of this information unless further disclosure is expressly permitted by your written authorization or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or otherinformation is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate orprosecute any alcohol or drug abuse person.

 

The consumer understands the terms of the consent and his or her right to obtain information on the disclosures.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730

Authorization for Release of Information

I authorize the following organization to release information as stated below from the client confidential record

 

As the person signing this authorization, I acknowledge that I am giving my permission to the above-named person/class of persons to disclose and use protected health information. I further acknowledge that:

• I may refuse to sign this authorization.
• The above-named person/class of persons cannot condition the provision of treatment to me on my signing this
• The original or a copy of this authorization shall be included with my original medical records.
• I have the right to revoke this authorization in writing at any time, but is not retroactive to information already released in
• accordance to the authorization.
• There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipient and, therefore, no longer protected by the provision of the HIPAA Privacy Rule. If this information is being disclosed from records protected by the Federal Substance Abuse Confidentiality Rules (42 CFR part 2), the Federal rules prohibit the recipient from making any further disclosure of this information unless further disclosure is expressly permitted by your written authorization or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse person.

The consumer understands the terms of the consent and his or her right to obtain information on the disclosures.

Comp Serv Health North Carolina

3971 Business Hwy 17 Bolivia

6209 Oleander Office 202 Wilmington

Telephone 888 751 3730