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HIPAA for Activity Directors

HIPAA for Activity Directors
By Chris Loga (ADN)

In the past year and half, one of the scariest words for activity directors has been… HIPAA! Throughout my travels, I have seen many of my colleagues shudder at the thought of a new set of rules and regulations.

Relax…

The good news is that HIPAA is not as scary as it has been made out to be. I have written this article specifically for activity directors and activity personnel. Since most of us are the makers of calendars, newsletters, banners, bulletin boards, etc., we need to know about the HIPAA policies.

The following article will hopefully ease your mind about HIPAA regulations. That way, you will be able to have your calendars, banners, bulletin boards and posters, while being in full compliance with all of the regulations.

What is HIPAA?



HIPAA or the Health Insurance Portability and Accountability Act was enacted in 1996 to help the federal government regulate the transferability of health insurance and to empower the government to fight fraud and abuse in long term care.

So what does that have to do with Activities?

In addition to the issues of health insurance, HIPAA was initially designed to regulate “individually identifiable” health information that was transmitted electronically. Since then, the “Privacy Rule” that is defined by HIPAA has expanded that concept.
So basically, a large amount of information that is crucial to Nursing homes can now be covered under HIPAA(2).  Since activities personnel deal with personal resident information, one of the areas for disclosure could be the activities department. In addition, the penalties for violating these rules are pretty steep ($100 to $25,000 per year, for each violation), so pay attention.


Is you facility a Covered Entity? You decide.

 The only facilities that will need to adhere to HIPAA are called Covered Entities. Covered Entities are defined as the following: Health care providers, Health Plans and Health Care Clearinghouses and Business associates. Each of these groups is expected to follow the guidelines that are described in HIPAA. Those groups that do not fall under the “Covered entities” description may not have to follow HIPAA.

 

Here it is in English. There are four basic groups that need to worry about the HIPAA regulations; in this article I will only look at one, the health care provider.
In general a health care provider is a nursing home, rehab facility, hospital or any other facility that provides skilled or intensive care.

 If you are not sure if your facility is a covered entity , please ask your administrator for clarification!


Personal Health Information-The nitty gritty of HIPAA

In terms of HIPAA, the information that they are worried about is called  “Personal Health Information” or PHI.  It can be best described as: any information that identifies an individual, that is received or created by a facility that contains information about the past, present or future physical or mental health of an individual. PHI can also include information on payment for medical services-however, I am intentionally staying away from that topic in this article.
This information is normally found in medical charts and billing files, however, it can be found in bulletin boards, Photo’s, Calendars and Birthday Cards, Activity Rooms and Common Areas and Activity Progress Notes. It is the highlighted areas that I will address in this article specifically.
All other information that I do not address, should be covered by your facility, in its “Privacy Policy”.
Each facility should have its own policy that is given to the resident on admission and to the staff who work at the facility. It is also not a bad idea for the activity department to follow a higher standard in regard to privacy, since we usually deal with the residents on a personal level, including but not limited to: family issues, special requests from the resident, newsletter articles, etc.

Please note: it is the responsibility of every employee to keep resident information confidential with regard to every aspect listed above. It is also the responsibility of each employee to know what types of information are covered under the HIPAA policy and under facilities’ privacy policy. Please educate yourself to the specific information in those policies in addition to using this as an education tool!


Now that all of the legal stuff is out of the way…

Now, you are sure that your facility is a covered entity and you know the definition of PHI. There are several ways to keep your department and residents safe with HIPAA regulations.  This is especially true when you realize that there are different ways to change medical information that are allowed under HIPAA regulations. First, lets look at the instances in which it is OK to reveal PHI.

 

Generally, the facility may provide PHI to family members, friends and clergy, such as:

1) The residents’ name and room number
2) The general condition of the resident-(e.g.- Ms. Smith is having a good day today, she went to Bible Study on her own. Not: Ms. Smith is feeling good because we gave her a double dose of medicine.)
3) The residents’ religious affiliation.

.

In the following examples, we will look at some ways, in which it is not allowed to disclose medical information

1) As you walk down the hall you hear 2 staff members- “I saw Mr. Jones last night and his delusions were really bad!” Besides being gossip, this is also disclosure of PHI and a violation of HIPAA.
2) As you are entering Care Plan information on your computer, you are called away; you leave the computer on with the information on the screen, Once again a violation, since anyone can come by and look at the computer.
3) You are expecting a fax from a hospital about an incoming resident; you do not pick up the fax until the day after. Once again, who can see the information? Remember, there are several ways to violate HIPAA regulations.

So let’s recap…we know that there are several ways to reveal information about residents, but what about information that we use everyday in our activity plans, bulletin boards and other publications?

Well, let’s take it piece by piece.

 

1) Photo’s – most facilities have a standard form in which the resident gives permission to take their pictures and is kept in the chart. This allows us to use a basic picture for whatever we need. However, if you put the resident’s name with that picture, you will be violation HIPAA. If you need to use a name (on a bulletin board for example) all you really need to do is ask the resident for permission and document it!
2) Calendars and Birthday cards- The best way to avoid the HIPAA regulations with regard to Birthday cards and calendars is simple. PHI can be de-identified by removing the birth year from any information. For example: Happy Birthday to Joe Smith -6/15! There is no other medical information that should be used on a calendar anyway so simply remove (diagnoses, dementia items, etc.) from the calendar.
3) Bulletin Boards and Miscellaneous- In almost every case with PHI if you take the proper steps to ask permission, you can prevent any confusion. If you have pictures, avoid putting names with them. If you must, get explicit permission and document. If you avoid using PHI with regard to residents you are in the clear.
4) Activity Rooms and Common areas- It is fine and dandy to use pictures of residents in your common areas. Please remember that no medical information can accompany the pictures. Do not identify residents by room or unit, especially if that resident resides on a memory/dementia care unit.
5) Activity and Progress Notes- All progress notes should be in the individual chart of the resident. If there is documentation outside of the chart, it needs to be shredded or placed into the chart itself. Pure and Simple…


In general, HIPAA is nothing to be afraid of for any Activity Director. The regulation was enacted to prevent privacy issues for residents of Nursing and Skilled care. If your activity department uses common sense to prevent improper disclosures you should be fine. Please feel free to use this article as a reference tool and double check with your administrator for individual questions.

2 New Activity Director CEU Workshops Online!

Activity Directors!!

We have just added 2 NEW ONLINE CEU WORKSHOPS!



*Activities for Limited English Speaking Residents- 8 CEUs $59.95

Activity Directors must be more creative when dealing with residents who have difficulty with the English language. It is common for people who have lived in America for many years and speak English fluently to lose the language as they show signs of dementia. Also, there is a growing population of individuals who have never learned the language or have moved to America recently and find themselves surrounded by strangers with whom they cannot communicate with. It is the Activity Director's job to seek out and discover activities to enrich the lives of those they serve; no matter the language barrier. This course will teach you to find your inner-creativity and offer activities that do not require English to be successful. Every resident, English speaking or not, will benefit from this course material.

Workshop Objectives:
- Understand barriers that residents and staff face when there is a communication problem.
- Be able to analyze which sources the Activity director has and which are needed.
- Find Activities and programs that benefit and enrich the lives of residents.
- Learn what steps to take in order to utilize the community resources.
- Have a clear understanding of the Activity Director's role when dealing with non-English speaking residents.

AND

*Motivate Yourself- 4 CEUs $24.95
Self-motivation is the force that keeps pushing us to go on - it's our internal drive to achieve, produce, develop, and keep moving forward. This workshop with help you work on how to become better motivated.

Workshop Objectives:
- Understand the importance of self motivation.
- Understand different techniques of motivation.
- Understanding ways to avoid burn out in your job.

Certificates of Completion available within 1 HOUR of completion! No driving, no inconveinence, no wait time, no problem! Visit
www.activitydirector.org and check it out:


Visit our Online Classroom at ActivityDirector.org for more info.. see you there!
1.888.238.0444  

CTRACTX.org Activity Director and Theraputic Recreation Certification in Texas Since 1996

Are you an Activity Director in Texas?
Do you need your Certification in Long Term Care, Assisted Living, Adult Daycare, Residential Care or Home Health?

Our Texas Basic and Texas Advanced Online Courses start this Tues. June 15th.. call Cheryl 888.238.0444
:: http://www.activitydirector.org ::



CTRACTX.org

In 1995, Dr. Tague, Dr. Jackie Vaughan, Randy Waters (then President of the Texas Recreation and Parks Society’s Therapeutic Recreation Branch) and several other interested professionals in the field began conduct conversations and gathering information regarding the interests of their colleagues in developing a certification program in Texas.
History of CTRAC Texas

In 1996, the TRAPS Therapeutic Recreation Branch (TRB) at a board meeting voted to provide supportive funds to establish a certification plan in Texas that would provide three levels of certification: the therapeutic recreation specialist level, the therapeutic recreation associate level and an activity director in long term care level.

We have developed a reciprocal agreement with the state of California. All of our TRS certificate holders are also considered certified in California, and vice versa. Already one Texas certificate holder has taken advantage of this agreement. To date, three people holding California certificates have taken advantage of this agreement as have two Texas certificate holders in California. In California, there is a practice act. Anyone who presents himself/herself as a TRS must be certified by the California credentialing board.

The Activity Directors Network hosts classes for CTRAC Texas and its Instructors. CTRAC Board Member and Director of Education, Dorothea Coleman-Brewer, conducts Online Classes Every 3rd Tuesday at http://www.activitydirector.org. Contact Cheryl at 888.238.0444 for details
May is the month for Mom..

National Nursing Home Week, National Nursing Week all coming in May..
on the funside .. we have * Bread Pudding Recipe Exchange Week .. * National Taffy Day.. * National Backyard Games Week.. * National Smile, * National Family and *Older Americans Days.. plenty of outdoorsy, social, family events to be planned.

Our -- May Newsletter -- is now live Online!
--
visit the Activity Director Forums at http://www.activitydirector.net/forum
click the Online Newsletter link on the top of the page.
~~~~~Online News~~~~~~~~
Direct Link : http://www.activitydirectorsnetwork.com/phplive/c.php?k=1.17.15
-- if this link does not work when clicked, simple cut-n-paste the http address into your browser bar
~~~~~~~~~~~~~~

-- check this activity out.. what do you think?

Adopt-a-Mom

Description: Adopt a Mom for Mother's Day (May 9, 2010) and help someone in community!

Instructions:
This program would be great to start on Mother's Day.
If you get great responses then you could adopt a mom monthly, quarterly or yearly.

Contact your local church to see if there are any single Moms that might need some support.
Have the residents do a craft sale or bake sale to make some money to donate to the Mom.
Have a food drive for the Mom.
Have the residents baby-sit for the Mom to give her a break.
Get donations from the community; grocery stores, children stores, restaurants, and other local business people.
Get an article in the paper to let your community know what you are doing to get more support! Make it a Mystery Mom..
--

~~~~~~Online News~~~~~~~
Direct Link : http://www.activitydirectorsnetwork.com/phplive/c.php?k=1.17.15
-- if this link does not work when clicked, simple cut-n-paste the http address into your browser bar
~~~~~~~~~~~~~~

Are you an Activity Director in Texas?
Do you need your Certification in Long Term Care, Assisted Living, Adult Daycare or Home Health?
Our Texas Basic and Texas Advanced Online Courses start this Tues. April 20th.. call Cheryl 888.238.0444
:: http://www.activitydirector.org ::
View the Activity Director certification requirements at :
** CTRAC The Consortium for Therapeutic Recreation and Activity Director Certification - www.CTRACTX.org

We have 2 CEU Workshops on Sale this Month
--
~~~~~~Online Classroom~~~~~~~
Direct Link : Online Classroom - http://www.activitydirector.org
-- if this link does not work when clicked, simple cut-n-paste the http address into your browser bar.
~~~~~~~~~~~~~~
** 1st - -- "are you ready for the New Guidelines f248-f249"
brush up on the Guidelines for Federal Tags f248-f249
248 refers to the duties and functions of the Activity Director
249 refers to the requirements and qualifications for Activity Directors
Included are the latest updates and revisions from CMS Medicare and Medicaid
On Sale! $59.95 Online Workshop 8 CEU hours
--
** 2nd - "Calendar Evaluation & Facility Population Assessment (FPA)"
Step by Step Calendar Activities balanced using your Facility Population Percentages.
Keep your Activity Program in compliance with a few simple steps.
Click n Print forms and illustrated examples to follow along. Reprint over and over.
On Sale! $39.95 Online Workshop 6 CEU hours
--

Online CEU Workshops Activity Directors Residential Care - AD Message Boards

Online CEU Workshops Activity Directors Residential Care - AD Message Boards

Visit the Activity Director Online Classroom at http://http//www.ActivityDirector.org for information on becoming Activity Director Certified or Qualified and avoid State Survey deficencies.

Keep your Certification current by attending the Online CEU Workshops available below.

CEU WORKSHOPS ARE ON SALE!
Sale Ends March 15th, 2010
"Course Name -"CEU's "Price
------------------------
Aromatherapy Assistant 4ceu - $49.95
Gaggle of Games 8ceu - $84.50
How to Have a Successful Bus Trip 8ceu - $79.95

--Activity Director Online Classroom at http://www.activitydirector.org/--

On Sale till March 15th
-----------------------
Gender Specific Planning- Men Mania - SALE! 4ceu - $19.95
Liven Up Your Exercise Program - SALE! 6ceu - $39.95
Fantastic Fundraising - SALE! 6ceu - $39.95
-----------------------

Marketing Your Activity Programs! 4ceu - $39.95
Integrating Wii Into Your Senior Program - 3ceu - $29.95
Calendar Evaluation & Pop Assessment 6ceu - $59.95
New Guidelines FTAG 248-249 8ceu - $79.95
Activity Analysis - How it Works 8ceu - $79.95
Alzheimer Awareness 8ceu - $79.95
Newsletters - The How to Workshop 4ceu - $39.95
Supplementing Budget Through Fundraising 4ceu - $39.95
Understanding the Basics of Dementia 8ceu - $79.95
Hospice: Creating Differences for the Patient 2ceu - $24.99
Care Plan: Culture Change 8ceu - $79.95
The Trick to Getting Your Staff Motivated 2ceu - $24.50
Recruitment & Selection of Quality Volunteers 8ceu - $79.95

--Activity Director Online Classroom at http://http//www.ActivityDirector.org--





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