Oaks of Hope's state licensed policies and procedures regarding client confidentiality is quite extensive because...
Client privacy is of the utmost importance.
To provide the highest quality treatment that meets or exceeds industry standards, and complies with local, state, and federal laws and regulations in regards to Clients rights.
Oaks of Hope is governed by Federal, State, County and accreditation regulations that protect the confidentiality of our Clients. We protect the privacy of individuals being treated at Oaks of Hope incompliance with CFR 42 and HIPAA Regulations.
Client identifying information is defined as the name, address, social security number or other similar information by which the identify of a Client can be determined with reasonable accuracy and speed either directly or by reference to other publicly available information.
I. Telephone calls:
1. Callers requesting information about a current or former Client at Oaks of Hope are to be
informed that under Federal confidentiality law, we are unable to confirm whether or not an
individual is or has ever been a Client at Oaks of Hope without the appropriate signed releases.
2. You may inform the caller that he/she is welcome to leave their name and telephone number and, if the individual in question is a Client, this information will be forwarded to the Client only if there is a consent form for the caller signed by the Client. The choice to contact the caller is the Client’s, depending upon whether or not the Client wishes to reveal that he/she is a Client of Oaks of Hope.
II. Postal Service:
1. Staff members who are responsible for picking up mail delivered to Oaks of Hope are not to pick up or accept Client mail that requires a signature. In such cases, the staff member must do the following:
a. Note the name of the sending party
b. Note the name of the individual the letter is being sent to and
2. The staff member is to call the Client and inform him/her that there is a letter/parcel that requires a signature at the post office and inform them of who is sending the parcel/letter.
3. If the Client requests that Oaks of Hope pick up the parcel/letter, that Client must sign a release form, allowing Oaks of Hope to make a disclosure to the Postal Service and the individual sending the letter.
All visitors/vendors must sign a Visitor’s/Vendors Log located at the reception office or other
designated areas. Affixed to this book is to be a notice of confidentiality, visitor’s responsibility
regarding confidentiality of any Client they may see at Oaks of Hope, and their obligation to follow the Federal Rules and Regulations. For additional guidance on issues of confidentiality, please refer to your supervisor, review release forms.
IV. Legal Issues and Confidentiality***Legal Reporting Requirements
1. Responding to Subpoenas, Search Warrants, and other Legal Actions
Individuals in treatment for alcohol and drug abuse have their privacy protected under Federal Law (United States Code, Title 42 §290ddB3 and ddE3) and the Federal Regulations that implement it (Title 42, Part 2 of the Code of Federal Regulations, a.k.a. 42 C.F.R. Part 2). It is extremely important that Oaks of Hope employees understand and
respond appropriately to all subpoenas, search warrants and other legal actions. No employee of Oaks of Hope may release any information, verbally or in writing, that identifies a Client as a
substance abuser or discloses information about her treatment unless these in a consent signed by the Client authorizing the release of such information. The only exception to this is in the case of a medical emergency that poses an immediate threat to health and requires immediate medical intervention.
Definitions: There are generally three types of subpoenas. The subpoena is a court order issued by an attorney or government agency requiring that a person appear in and/or testifies in court or in front of an agency. The subpoena duces tecum is a court order that instructs a person to provide certain documents, such as medical or employee records, to a court, attorneys office or government agency. This subpoena may also demand the person accompany said documents and give testimony as a witness. The grand jury subpoena is a court order that indicates a criminal investigation is being conducted and the recipient is summoned to appear as a witness or to testify.
Subpoenas are not the type of court order required by the confidentiality regulations, therefore Oaks of Hope is prohibited from responding to them by disclosing information concerning current or former Clients unless said Client has signed a consent to authorize such a disclosure. Subpoenas that request Client records are to be directed to the Clinical Director, those requesting employee files are directed to the CEO, and all others are to be given directly to the CEO, who will seek legal counsel to examine and advise a course of action. The procedures to be followed for release of this information are outlined in Oaks of Hope’s policy regarding Consent to Release Form.
2. Responding to Warrants, Court Orders and Audits
Search warrants may not be used to allow law enforcement officers to enter Oaks of Hope’s facilities. This would breach the confidentiality regulations protecting all Clients in the facility. However, arrest warrants do permit law enforcement officers to enter, but only to search for a particular Client who has committed or threatened a crime on the Oaks of Hope premises or against Oaks of Hope personnel.
Unless the arrest warrant is accompanied by a proper court order, Oaks of Hope need not cooperate with a search for a Client who has committed a crime elsewhere. If a law enforcement officer or government agent shows up at Oaks of Hope with either an arrest warrant or search warrant, employees must contact the Clinical Director, to ensure the protection of the staff and Clients. If this occurs at a time when the Clinical Director cannot be reached, personnel may contact the Executive Director/CEO.
Special Exception to the above rules governing warrants: If a Client in treatment is already aware she has a warrant and wishes to allow a law enforcement officer or government agent to come to Oaks of Hope to serve them with it, staff may have the Client sign a consent form outlining this (refer to Oaks of Hope’s policy regarding a Consent to Release Form on how to complete this form).
3. Court-Order Disclosures.
Courts, both federal and state, may issue an order compelling Oaks of Hope to release information that would otherwise be forbidden. These orders may only be issued after the court follows certain procedures and Oaks of Hope has the right to request this process be done prior to disclosing any information. Note: a subpoena, search warrant, or arrest warrant alone, even when signed by a judge, is NOT sufficient to permit or require Oaks of Hope to make such a disclosure. First, a program or Client whose records are sought must be given notice of the application for the order and the opportunity to make an oral or written statement to the court regarding said application. Prior to the order being issued, there must be finding of good cause for the disclosure. Only that information which is essential for the purpose of the order may be released and only those persons who need the information may receive it. The procedures to be adhered to for release of this information, once proper procedures to obtain a court order have been followed, are outlined in Oaks of Hope’s policy regarding a Consent to Release Form.
Audits of Oaks of Hope’s files may be deemed appropriate and necessary by a government agency, third party payer (i.e. insurance company), or peer review organization. These persons or agencies may review Oaks of Hope records without Client consent as long as they have agreed in writing that they will not disclose Client identifying information, unless it is pursuant to a court order to investigate or prosecute Oaks of Hope and not a Client.