TARRY HOUSE, INC.
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Subject: Records
Policy; Confidentiality, Security, and
Disaster Plan |
Procedure Number:
C.P. 02 |
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Site: Tarry House and Tarry House Respite |
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Issued By: Executive Director |
Effective: |
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Approved By: The Board of Trustees |
Revised: |
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Reference Policy: M.L. 06 |
Reviewed: |
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Standards Reference: |
CARF: Section 1.C. & 2. C. ODMH: 5122-30-23 |
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I.
Purpose
To provide for the safe and secure use and storage of
confidential information of those served contained within person served
records. To reasonably
protect electronic records against fire, water damage, and other hazards.
II.
Policy
It shall be the policy of Tarry House, Inc. to maintain systematic
and uniformly organized record for those served. All recorded information on those served will
be kept in locked offices or retained in locked files and reasonably protected
against fire, water damage and other hazards. Electronically stored information
on those served will maintained on the computer’s hard drive as well as back-up
disks with password protection as needed.
Back-up files will be stored in the large fire retardant safe in the Administrative
Office.
III.
Procedure
All current files of those served will be centrally located
in the Recovery Staff Office. Staff will
have access to records as directed by the Clinical Director. Any person served may review his/her Tarry
House, Inc. clinical record. The request
may be made verbally or in writing to any staff member. The request will be
forwarded to e the Clinical Director who will then contact the person served
within two (2) working days to make arrangements for a review. The review will
take place within seven (7) working days of the person’s served request in the
presence of the Program Manager or the Clinical Director. However, documents developed by another
agency are not open to persons served. The person served must contact the
primary agency for access to those documents, and produce a signed release of
information form indicating what documents the other agency has
agreed to release to the person served. All
staff is responsible to ensure that the confidentiality of person served
information is maintained at all times.
Access to person served information by non-staff members will require
court order, a signed release of information by the person served, or a
Business Associates Agreement (BAA) between agencies.
Tarry House, Inc. will retain the clinical/recovery records of
persons served for a period of seven (7) years after discharge. All closed cases are retained in locked file
cabinets. It is the responsibility of the Tarry House, Inc. Clinical Director
or designee to schedule the destruction of clinical records by implementing the
following steps:
A. The
Clinical Director will give the Executive Director a list of the clinical
records that are due to be shredded.
B. The
Executive Director will secure a vendor who is bonded and insured and that
guarantees the confidential and complete shredding of documents or will have
the shredding completed completely and confidentially in house.
C. Should
there be a legal action filed against the organization in reference to a person
served and that individual’s record has been identified for destruction, it is
the responsibility of the Executive Director to ensure the shredding of that person’s
record is stopped. That clinical record
will continue to remain locked until the legal action has ended. It is the responsibility of the Executive
Director to solicit legal advice prior to this record’s shredding.
RESPONSIBILITIES:
The Executive Director and the Clinical Director shall be
responsible for the secure storage of all person served records. The Program Manager and the Recovery Specialist
will be responsible for the development and maintenance of person served
records.
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Executive Director Date