Our Policies

Notice of Privacy Practices

Holy Family Institute and Its Affiliates

Notices of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

WHO WILL FOLLOW THIS NOTICE

This notice describes the information privacy practices followed by our employees and volunteers.

YOUR HEALTH INFORMATION

This notice applies to the information and records we have about your mental and/or physical health and the services you receive at Holy Family Institute.

We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose information about you and describes your rights, as well as our obligations regarding the use and disclosure of that information.

In all cases when we disclose information about you we will only provide the minimum necessary information to meet the requirement in order to ensure the highest level of privacy.

The confidentiality of alcohol and drug abuse patient records is specifically protected by Federal law 42 CFR Part II and state laws 28 Pa Code 709.28 and 4 Pa Code 255.5. We are required to comply with these additional restrictions. This includes a prohibition, with very few exceptions, on informing anyone outside of the program that you are attending or have attended the program or disclosing any information that identifies you as an alcohol or drug abuser. The exceptions are as follows: you consent in writing, the disclosure is allowed by a court order, the disclosure is made to medical personnel in a medical emergency, the disclosure is made to designated and qualified staff for research, audit, or program evaluation, the disclosure is regarding information about a crime committed by a patient either at this program or against any person who works for the program or about any threat to commit such a crime, and disclosure of information regarding suspected child abuse or neglect to appropriate state or local authorities.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment

We may use information about you to provide treatment or services. We may disclose information to therapists, doctors, nurses, or other personnel who are involved in taking care of you. For example, a treatment team comprised of various professionals may meet to help determine the most appropriate care for you and are permitted to disclose health information to determine the best course of treatment.

For Payment

We may use and disclose information about you so that the treatment and services you receive at Holy Family Institute may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a service received here so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will cover the treatment.

For Health Care Operations

We may use and disclose health information about you in order to run the organization and make sure that you and our other clients receive quality care. For example, we may use treatment information to evaluate and improve the quality of services that we provide to clients.

Appointment Reminders

We may contact you as a reminder that you have an appointment for treatment.

Please notify us in writing if you do not wish to be contacted for appointment reminders.

SPECIAL SITUATIONS

We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety

We may use and disclose treatment information about you when necessary to prevent a serious threat to the health and safety of you, the public or another person.

Required By Law

We will disclose treatment information about you when required to do so by federal, state or local law.

Research

We may use and disclose treatment information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your address or other information that reveals your identity.

Military, Veterans, National Security and Intelligence

If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release treatment information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation

We may release treatment information about you for workers’ compensation or similar programs. These programs provide benefits for work‑related injuries or illness.

Public Health Risks

We may disclose treatment information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non‑accidental physical injuries, reactions to medications or problems with products.

Health Oversight Activities

We may disclose treatment information to a health oversight agency for audits, investigations, inspections, risk management or licensing requirement purposes. These disclosures may be necessary for certain state and federal agencies to monitor government programs and compliance with civil rights laws.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, we may disclose treatment information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose treatment information about you in response to a subpoena.

Law Enforcement

We may release treatment information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Coroners, Medical Examiners and Funeral Directors

We may release treatment information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Information Not Personally Identifiable

We may use or disclose treatment information about you in a way that does not reveal your identity.

Family and Friends

We may disclose treatment information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose treatment information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal treatment information to your spouse when you bring your spouse with you into a treatment session where treatment is discussed.

In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only information relevant to the person’s involvement in your care.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

We will not use or disclose treatment information for any purpose other than those identified in the previous sections without your specific, written authorization. The following uses and disclosures, with limited exceptions, require authorization:

  • Direct disclosure of a child’s PHI to the child’s school to permit the child’s participation in sports activities
  • Sale of a client list
  • Disclosure of PHI to an employer
  • Disclosure of PHI to a life insurer for underwriting/eligibility for insurance
  • Disclosure to an attorney
  • Fundraising
  • Marketing

If you give us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose information about you for the reasons covered by your written authorization, but we cannot take back any uses or disclosures already made with your permission. In order to revoke an authorization, submit the Revocation of Authorization form and submit to the Privacy Officer.

If this health information concerns substance abuse and/or HIV status, we may be very limited in what we provide and may be required to first obtain specific authorization from you.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding treatment information we maintain about you:

Right to Inspect and Copy

You have the right to inspect and copy treatment information regarding you, such as medical records, that we use to make decisions about care. To request to review or inspect a copy of your record, submit the Client Request to Review or Obtain Copy of Health Information form to the Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to Amend

If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by Holy Family Institute.

To request an amendment, complete and submit a Client Request to Amend Health Information form to the Privacy Officer. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

a) We did not create, unless the person or entity that created the information is no longer available to make the amendment.
b) Is not part of the treatment information that we keep.
c) You would not be permitted to inspect and copy.
d) Is accurate and complete.

You also have the right to submit a rebuttal statement to your own records for any information contained in your records that you do not feel is correct.

Right to an Accounting of Disclosures

You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. Please note that this accounting of disclosures will not include the following:

  1. Disclosures made for treatment, payment, and/or healthcare operations
  2. Disclosures made for a facility directory
  3. Incidental disclosures
  4. Disclosures made based on your written authorization
  5. Disclosures made to you
  6. Limited disclosures to persons involved in your care
  7. Disclosures made for national security or intelligence purposes
  8. Disclosures made to law enforcement officials or correctional institutions about you while in their legal custody
  9. Disclosures that were part of a limited data set, or information that has been de-identified
  10. Disclosures made more than six years prior to the date of your request

To obtain this list, complete and submit a Client Request for Accounting of Disclosures of Health Information to the Privacy Officer. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003.

Right to Request Restrictions

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the treatment information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. In order to request a restriction, complete the Request for Restricting Uses and Disclosures of PHI form and submit this form to the Privacy Officer.

We are Not Required to Agree to Your Request*

If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

*We are required to agree to a request for restriction if you pay in full for an item or service “out of pocket” and you request restriction on disclosure of your PHI, which pertains solely to this item or service, with respect to your health plan or insurer for purposes of carrying out payment or healthcare operations (not treatment).

Right to Request Confidential Communications

You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you may complete and submit the Request for Alternative Means or Location of Confidential Communications form to the Privacy Officer. We may ask you the reason for your request but can not require that a reason be provided. We will accommodate all reasonable requests, as determined by Holy Family Institute. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact the Privacy Officer.

Right to Breach Notification

Upon determination that breach notification is required, you have the right to be notified without unreasonable delay and no later than 60 calendar days after the discovery of the breach. The notice will include: a brief description of what happened, the type(s) of unsecured protected health information that was involved, any steps you should take to protect yourself from potential harm resulting from the breach, a brief description of what we will do to investigate the breach, mitigate harm to individuals, protect against further breaches, and contact procedures for individuals to ask questions or obtain additional information.

HOLY FAMILY INSTITUTE OBLIGATIONS

Holy Family Institute has the obligation to maintain the privacy of your protected health information. We also have the responsibility to abide by the terms of the notice currently in effect.

CHANGES TO THIS NOTICE

We reserve the right to change this notice, and to make the revised or changed notice effective for treatment information we already have about you, as well as any information we receive in the future. We will post the current notice in conspicuous locations in offices and on our website with the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact the Privacy Officer. You will not be retaliated against for filing a complaint

PRIVACY OFFICER INFORMATION
Carmella Miller
Privacy Officer
8235 Ohio River Boulevard Pittsburgh, PA 15202
412-766-9020 x255
miller.carmella@hfi.pgh-org

This notice is effective April 14, 2003.
Revised February 17, 2011
Revised July 7, 2011

Quality Information Stakeholder Overview

Holy Family Institute and Its Affiliates

Quality Improvement Stakeholder Overview

Purpose of Quality Improvement: Holy Family Institute (HFI) and its affiliates are committed to fostering a culture of quality and accountability. By monitoring performance indicators and using data to continuously improve our services and drive decision-making, we can ensure that HFI and its affiliates continue to provide high quality services.

Quality Improvement Principles: HFI’s and its affiliate’s approaches to quality improvement are based on the following principles:

  • Customer/Consumer Focus – We focus on both our internal and external customers and consumers, and on meeting or exceeding needs and expectations.
  • Employee Empowerment – In order to be effective, people at all levels of the organization are involved in improving quality.
  • Leadership Involvement - Strong leadership, direction, and support of quality improvement activities by the governing body and Administrative Team are key to our successful implementation of quality improvement.
  • Data-Informed Practices – We create feedback loops, using data to inform practice and measure results. Fact-based decisions are likely to be correct decisions. Some methods used to collect data include, but are not limited to:
  • Proactive Over Reactive – We seek to design good processes to achieve excellent outcomes rather than fix processes.
  • Continuous Improvement – Processes must be continuously reviewed and improved.

Quality Improvement Priorities: Quality improvement priorities will focus on those processes that are:

  • High risk – processes or program/departmental areas that place consumers and/or staff at risk.
  • High volume – processes that occur frequently or affect large numbers of consumers and/or staff.
  • Requirements from regulatory agencies or accrediting bodies, ie. COA, DPW, PDE, etc..
  • Sentinel events.
  • Impacting upon HFI and its affiliate’s ethics or values.
  • Exhibiting levels of performance that vary significantly from expectations.
  • Exhibiting levels of performance that vary undesirably from comparison data.
  • Directly related to strategic goals.

Quality Improvement Structure:

Risk, Compliance, and Quality Management (RCQM) Board Subcommittee

Structure and Responsibilities

The purpose of the RCQM Board Subcommittee is to review high-level organizational risk, compliance, and quality information and provide oversight to the quality, risk, and compliance activities of the organization. This Subcommittee reviews the following information:

  • External Licensing Reviews
  • Client Record Reviews
  • Incidents/Accidents (staff and client)
  • Client Satisfaction
  • Grievances and Allegations
  • Client Outcomes
  • COA Self Reports

Quality Committee

Structure and Responsibilities

The purpose of the Quality Committee is to provide oversight of the quality and risk activities of the organization. The Quality Committee is responsible for reviewing data to identify opportunities for improvement and areas of strength. The Quality Committee assesses whether changes in procedures achieved the anticipated outcome and whether established measures have been met.

Safety Committee

Structure and Responsibilities

The purposes of the Safety Committee include:

  • Establish and monitor performance measures and develop, communicate, and recommend action plans related to:
    • Facility and motor vehicle safety and security
    • Emergency management
    • Consumer and staff injuries
    • Worker’s compensation
    • Consumer critical incident
    • Other items as deemed appropriate
  • Proactively prevent potential occurrences of future injury or incidents

Restraint Review Committee

Structure and Responsibilities

The purposes of the Restraint Review Committee include:

  • Review each individual restraint for: compliance with regulations, proper utilization of techniques, proper/thorough completion of paperwork
  • Identify concerning issues with individual restraints, as well as trends or patterns that need to be corrected
  • Utilize information gleaned to inform future CPI trainings

Stakeholders

Stakeholder involvement in Quality Improvement is solicited in many different ways at HFI and its affiliates:

  • Staff Satisfaction Survey – Annual
  • Consumer Satisfaction Surveys- Annual for all and at Discharge for In-Home, SHORES (Support Hours of Recovery to Ensure Sobriety), SNAP™ (Stop Now and Plan™), and Residential
  • External Stakeholder Survey (caseworkers, referring entities, etc.) – Annual
  • Staff Exit Survey – On-going
  • Consumer Follow-Up Survey – 6 and 12 months for Residential
  • Red Flag Meetings – Staff at any level in the organization can initiate a Red Flag Meeting to discuss issues that are problematic. These meetings lead to improvement activities that are monitored through appropriate program and/or department personnel.

Management/Operational Performance

In terms of management/operational performance, the organization collects, analyzes, and acts on the following indicators:

  • Staff turnover
  • Staff satisfaction (exit and annual)
  • Financial stability
  • Staff injuries
  • Facility safety and security

Program Results/Service Delivery Quality

In terms of program results/service delivery quality, the organization collects, analyzes, and acts on the following indicators:

  • Client satisfaction
  • External stakeholder satisfaction
  • Consumer critical incidents/accidents
  • Restrictive procedures
  • Medication incidents
  • Chart audits
  • Grievances
  • Allegations

Client and Program Outcomes

In terms of client and program outcomes, the organization, collects, analyzes, and acts on the following indicators:

Residential

  • Case status at discharge
  • Goal success rating at discharge
  • Restrictiveness of discharge placement
  • Academic success
  • Permanency and school/employment at 6 and 12-months post-discharge

Education

  • Individualized Education Plan (IEP) goal progress
  • Change in Grade Point Average (GPA)
  • Pennsylvania System of School Assessment (PSSA) practice test results

Outpatient

  • Case status at discharge
  • Change in Global Assessment of Functioning (GAF) score
  • Goal success rating at discharge

In-Home

  • Number of children residing in a family setting at discharge
  • Number of families with reduced risk scores at discharge
  • Achievement of identified goals at discharge
  • Number of families connected to community resources at discharge
  • Independent youth will complete their plans (Armstrong In-Home Independent Living only)

Family Focused Solution Based (FFSB)

  • Number of children residing in a family setting at discharge
  • Number of families with reduced GAF scores at discharge
  • Achievement of identified goals at discharge
  • Number of families connected to community resources at discharge

Family Group Decision Making

  • Number of children remaining within a family setting at discharge
  • Number of families who established a goal plan at discharge
  • Number of families who implemented their goal plans at discharge

SHORES

  • Case status at discharge
  • Goal success rating at discharge

SNAP™

  • Change in Child Behavior Check List (CBCL)
  • Change in Teacher’s Report Forms (TRF)
  • Change in Earl 20-B
  • Change in Self-Report Antisocial Behavior (SRA) Score

Improvement Model

HFI and its affiliates have selected the Shewhart Plan-Do-Study-Act (PDSA) model as its method of improving organizational performance. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test or trying it (Do), observing and learning from the consequences (Study), and then acting on what is learned from those consequences (Act), a process that is iterative.