Before my visit, and if applicable to my visit, I understand that:

I will be required to submit the company proof of the following:

• A negative annual TB skin or blood test (if positive TB reactors, documentation of medical evaluations, chest x-rays, laboratory tests, treatment, and monitoring per state regulations)
  • Influenza vaccination in accordance with CDC recommendations
  • Immunity to the following Communicable Diseases:
  • MMR
  • Varicella
  • Tdap
  • Hepatitis B - recommended but not mandated
• I must represent and warrant to Company that I have not been convicted of any state or federal law felony.
• I may be required to undergo a criminal background check.

Photography Statement

I understand that my experience as a clinical student may be onsite at a Company property or community location, or at any place a Company patient is located (e.g., patient’s personal home, another healthcare facility, etc.). I understand that the Company serves patients in all areas and zip codes of its assigned community, and wherever a patient calls ‘home.’ I understand that certain Company locations and patient homes/locations may have cameras, and I may be recorded. Company cameras are not monitored.

I am not permitted to and will not take photographs or use cameras or recording devices of any kind during my visit, for any reason.

Confidential Information and HIPAA Privacy Safeguards

{affiliate}

POLICY STATEMENT
 
Company board members, staff and volunteers (including but not limited to committee members, students and interns), collectively referred to hereinafter as "Workforce," and other guests of Company are required to ensure the confidentiality of protected health information (PHI), proprietary information and personnel information, collectively referred to hereinafter as "Confidential Information."

Each Covered Entity must have in place appropriate administrative, technical, and physical safeguards to protect the privacy of PHI, in accordance with 45 C.F.R. § 164.530(c). Thus, Company must reasonably safeguard PHI from any intentional or unintentional use or disclosure that is in violation of the standards, implementation specifications or other requirements of the HIPAA Privacy Rule. In addition, Company must reasonably safeguard PHI to limit incidental uses or disclosures made pursuant to an otherwise permitted or required use or disclosure. Accordingly, Company adopts the procedures set forth below to ensure compliance with this policy and Company's duty to safeguard PHI of its patients.

PROCEDURE
 

• Members of the Workforce and other guests of Company are required to protect Confidential Information in a manner that protects both its integrity and confidentiality and in accordance with Company policies and procedures. Specifically, Confidential Information is never:
  • left unattended in public areas in or outside Company;
  • left in private areas that are not properly secured;
  • placed in trash cans, even on Company property;
  • disclosed to anyone who has not been authorized to receive it;
  • discussed in public where unauthorized individuals might overhear; or
  • transmitted electronically via an unsecured connection (i.e. outside Company email and other approved systems).
• Company requires members of its Workforce and other guests of Company, as appropriate, to sign a Confidentiality Statement prior to accessing Confidential Information.
• Confidentiality Statements are maintained as part of the Workforce member's file (or other appropriate file if signed by a guest) by the appropriate department and in accordance with Company' Retention of Records policy (i.e., Human Resources, Volunteer Department, Education Department, Administration).
• Staff members do not take friends or family members with them to patient/client/family visits either during regular hours or while on-call. A Company contracted security guard can be requested to accompany staff if there are concerns about safety. Rare exceptions may be made when weather or driving conditions are hazardous. These situations should be handled with careful attention to preserving confidentiality to the fullest extent possible.

Confidentiality of Documentation
 

• Documentation and other paperwork carried by staff are maintained in a manner that protects confidentiality.
  • Documentation is not left unattended in public areas, including Company facilities (i.e. kitchen, team meeting rooms, copy room, staff work area).
  • Documentation temporarily kept in a staff member's vehicle or home is maintained in a manner that prevents any person from reading names on records or seeing any identifying information.
  • Patient/client files kept within Company facilities are maintained in secure locations.
  • When no longer needed, staff copies of patient/client/family documentation are placed in secure shredding bins. Staff does not dispose of confidential information in the regular trash receptacles.
• The name of one Company patient/client should not appear in the record of another.
• When information from the medical record, or in any way pertaining to a patient/client or family, must be FAXED, a cover sheet with a statement concerning the confidential nature of the accompanying information is used. The statement instructs the receiver to contact the sender immediately to confirm destruction if the recipient has received the communication in error. Staff double checks the recipient's fax number before transmittal and reviews reports indicating if there has been an error in the transmission of the information.
• Fax machines should be checked frequently to insure that faxes containing PHI are removed promptly.
• When a Company Workforce member mails a document that contains PHI, he or she shall double check the mailing address to ensure the PHI is being sent to the correct person and to ensure that the label does not contain any additional unnecessary information.
• Company Workforce members shall not save PHI to electronic mobile storage devices or other mobile storage media unless it is absolutely necessary. In the event such information is saved to such devices, the workforce member shall contact IT support before saving such information to determine the most secure way to save the PHI. In addition, the device shall be encrypted (if possible) and safeguarded to protect the PHI.

Observation and Involvement by Non Workforce Members
 

• Students involved in supervised field placements are permitted to observe or be involved with Company patients/clients and families receiving care/services. The student's educational institution must have a signed affiliation agreement with Company that has been updated to comply with the Administrative Simplification requirements of the Health Insurance Portability and Accountability Act of 1996. (HIPAA) (See Business Associates).
• Faculty supervising students placed at Company are expected to emphasize and enforce Company' s policies and procedures related to privacy and security of PHI.
• Persons visiting Company for business purposes such as employees of another hospice are required to sign a Confidentiality Statement. This statement is kept on file.
• Only researchers who have been approved by the Research Committee are permitted to have patient/client/family contact.
  The patient's/client's permission is secured prior to the observation and/or involvement of persons other than primary team members. This may be done verbally by staff and documented in the patient record.
• Extenuating circumstances may also necessitate adaptation.

Confidentiality & HIPAA Acknowledgement

I have read and understand the Confidential Information and HIPAA Privacy Safeguards policy for {affiliate}. I agree to protect all confidential information, including PHI, and follow all security and privacy requirements.

Confidentiality Policy

{affiliate} and Affiliates

This Confidentiality Policy applies to all employees, board members, external board and internal committee members, officers, volunteers, and students of {affiliate}, and its Affiliates (including all legally associated entities and business). 

Legal and Regulatory Requirements

• In addition to all applicable Company policies, all Confidential Information must be managed in accordance with all applicable federal and state laws, including HIPAA Privacy Regulations (45 CFR, Parts 160 and 164), KRS 210.235, and other applicable Medicare guidelines, accrediting agency requirements, and professional codes.
• All Company vendors and accrediting agencies must comply with same  to protect patient and family confidentiality.

Policy Guidelines

• Abide by all Company policies and applicable Legal and Regulatory Requirements relating to confidentiality and Confidential Information.
• Maintain and secure all Confidential Information to protect its integrity at all times, and return or dispose of it in accordance with Company policy when no longer needed.
• Promptly notify a supervisor or other management, the Compliance or Chief Legal Officer, or the Compliance Hotline of any suspected or actual unauthorized access, improper disposal, accidental improper sharing, or loss of Confidential Information, including issues with passwords, physical documents, Company issued equipment, or electronic information of any kind.
• Exercise caution to prevent the inadvertent written, verbal, or other disclosure or transmission of Confidential Information, especially PHI, to persons not authorized or not engaged in direct patient care.  This means that unless specifically authorized for your position or approved, share Confidential Information internally only and only with those on a ‘need to know’ or authorized basis.
• Use all Company information and communication systems in a manner that prevents unauthorized viewing or access to Confidential Information and log off when appropriate.
• Never misuse or knowingly permit others to use assigned or secondary passwords.
• Do not electronically transmit PHI outside of secure, approved Company systems or to third-parties (unless authorized or permitted by law).
• Keep all passwords, building access keys, and other relevant credentials confidential and secure at all times.

Disciplinary Actions and Reporting

• Any violation of this policy may result in disciplinary action, including termination of employment and may subject violating individuals to penalties such as fines up to $250,000 or imprisonment for up to ten (10) years, or both, under HIPAA Privacy Regulations.
• Company may be required to report certain violations  to the professional licensing boards and other third-party agencies, and disclose said violations  to the affected individual (e.g., patient or their legal representative), as required by law.

Agreement

By signing below, I acknowledge the hand hygiene practices and understand that photography of any kind is prohibited during my time with the Company. I acknowledge the particular importance of strict adherence to confidentiality and the protection of Confidential Information within a healthcare organization like Company. I agree to comply with and uphold the Company’s Code of Conduct, including all applicable policies, standards, and expectations governing ethical and professional behavior. I agree to uphold the confidentiality of all information obtained through my association with Company, whether received from others, found in medical records, or obtained through my personal observation. I will act to protect all work-related passwords, authorized system access, and Company issued keys and equipment as part of my commitment to confidentiality and the protection of all Confidential Information. I understand there are serious consequences, both legally and Company imposed, that could occur with my non-compliance of this policy.