Your Information. Your Rights. Our Responsibilities.
This notice is required by federal law and describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we have shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we:
- Tell family and friends about your condition
- Provide disaster relief
- Provide health care
- Provide mental health care
- Market our services
Our Uses and Disclosures
We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
EFFECTIVE DATE: 12/01/2013
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we will tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we have shared information
- You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free. We will charge a reasonable, cost-based fee if you ask for another disclosure within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting our Privacy Officer. If you have questions or concerns about your privacy rights or feel your privacy rights may have been violated, please do not hesitate to ask to speak with the facility’s Privacy Officer or to contact the Privacy Officer directly.
Name of Privacy Officer: Mark Solomon
Phone: (847) 675-7979
Fax: (847) 675-0555
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint. Contacting our Privacy Officer or making a complaint will in no way diminish the care and/or services you receive at our facility.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a facility directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes/mental health treatment records, substance abuse treatment records, or notes regarding AIDS/HIV testing, treatment or counseling
We never sell personal information.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Appointment reminders and health care counseling
We may contact you, or those with whom you direct us to share information, to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
- We are required by law to maintain the privacy and security of your protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Bryn Mawr Care is committed to conducting its business in compliance with all federal, state and local laws. In some circumstances, the interpretation and application of the law is highly technical, and common concepts of right and wrong lend little guidance. Thus, employees, who believe that they are conducting themselves properly may, in fact, be violating applicable laws. Violations of the law by employees, even unwitting violations, can subject Our Facility and the person to the risk of penalties and embarrassment. However, effective adherence to the Compliance Plan will assure employees of a maximum blanket of insulation from negative actions by others.
Bryn Mawr Care can meet this commitment only through the efforts of our highly skilled care givers and dedicated support staffs. It is they who must earn the trust and respect of nursing home residents (“residents”), family members, the community and others by continuing to conduct their daily affairs with honesty, integrity, and in compliance with the letter and spirit of all applicable laws. Although honesty and integrity are individual attributes, and each individual ultimately is responsible for his or her own conduct, Our Facility is committed to maintaining a working environment that promotes these ideals and permits our employees to demonstrate the highest ethical standards in performing their daily tasks.
In order to avoid violations of law, Bryn Mawr Care has implemented a formal Corporate Compliance Program concerning its nursing home practice operations. Our action in proceeding in the development and implementation of a Corporate Compliance Program should not be interpreted as concern that present management systems are inadequate. Rather, development and implementation of a Corporate Compliance Program is an element in Our Facility’s continuing effort to improve quality and performance. Federal and state agencies responsible for enforcement of Medicare and Medicaid laws and regulations applicable to healthcare providers recently have encouraged the development and implementation of Corporate Compliance Programs by healthcare providers. Because this facility is continually reviewing its compliance procedures, and because the government issues regulation changes from time to time, this Compliance Manual is fluid in that it is in a continual state of revision and updating.
Our Program will:
1. Meet or exceed the seven elements (see below) of an effective compliance program recommended by the Department of Health and Human Services’ Office of Inspector General (“OIG”). These require an organization to:
- implement written policies, procedures and standards of conduct;
- designate a Compliance Officer, the Facility Compliance Liaison and Compliance Committee;
- conduct effective training and education;
- develop effective lines of communication;
- conduct internal monitoring and auditing;
- enforce standards through well-publicized disciplinary guidelines; and
- respond promptly to detected offenses and develop corrective action.
2. We will develop and implement specific standards, educating and training employees with respect to those specific standards, and reviewing and possibly enhancing internal controls and monitoring systems. Implementation will proceed in phases, but management should make steady progress toward the creation and implementation of specific standards and systems relating to all material areas of Bryn Mawr Care’s operations where there are compliance obligations. The Corporate Compliance Committee through the Compliance Officer shall provide periodic progress reports to the Board of Directors.
II. ADMINISTRATION AND APPLICATION OF THE CODE OF CONDUCT
Bryn Mawr Care expects each person to abide by the Principles and Standards set forth herein and to conduct the business and affairs of Our Facility in a manner consistent with the general statement of principles set forth herein.
Failure to abide by the Code of Conduct or the guidelines for behavior which the Code of Conduct represents may lead to disciplinary action. For alleged violations of the Code of Conduct, the Administrator (Compliance Liaison) and Compliance Officer will weigh relevant facts and circumstances, including, but not limited to, the extent to which the behavior was contrary to the express language or general intent of the Code of Conduct, the seriousness of the behavior, the employee’s history with the organization and other factors which they deem relevant. Discipline for failure to abide by the Code of Conduct may, in our (Administration’s) discretion, range from oral correction to termination. Prior to administering termination action, we may seek the concurrence of our Counsel. In the event that an employee is covered by the terms of a collective bargaining agreement, discipline shall be in accordance with the provisions of the collective bargaining agreement.
Nothing in this Code of Conduct is intended to nor shall be construed as providing any additional employment or contract rights to employees or other persons. While Bryn Mawr Care will generally attempt to communicate changes concurrent with or prior to the implementation of such changes, Our Facility reserves the right to modify, amend or alter the Code of Conduct without notice to any person or employee. After a change in the Code of Conduct is made, all employees will be so notified.
III. DEFICIT REDUCTION ACT
Bryn Mawr Care is committed to its role in preventing health care fraud and abuse and complying with applicable state and federal law related to health care fraud and abuse. The Deficit Reduction Act of 2005 requires information about both federal False Claims Act and other laws, including state laws, dealing with fraud, waste and whistleblower protections for reporting these issues. To ensure compliance with such laws, Bryn Mawr Care has policies and procedures in place to detect and prevent fraud, waste, and abuse, and also supports the efforts of federal and state authorities in identifying fraud and abuse.
An individual is not required to report any allegations of False Claims, abuse or fraud violations to Bryn Mawr Care first. A report may be made directly to the Federal or State Departments of Justice, or the Offices of Inspector General. However, in many instances Bryn Mawr Care believes that use of its own internal reporting process, and the internal compliance program is a better option because it allows Bryn Mawr Care to quickly address any potential issues. Bryn Mawr Care encourages contractors, employees or any other concerned individuals to consider first reporting suspected false claims, abuse or fraud issues to the facility administrator or the corporate compliance officer. Bryn Mawr Care will not retaliate against any individual for informing us or the federal or state government of possible violations.
Concerns of Compliance, False Claims Acts, fraud or abuse can be reported to:
Mark Solomon, Compliance Officer
6840 N. Lincoln
Lincolnwood, IL 60712
Compliance Hotline: 847-679-ABUSE
CODE OF CONDUCT
Purpose of the Code of Conduct:
Provides all employees, directors and owners of Bryn Mawr Care guidance in carrying out their regular daily activities within appropriate ethical and legal standards. This code of conduct applies to our relationships with residents, vendors, consultants and each other.
The Code of Conduct is a critical component of our Corporate Compliance Program.
It contains principles that state the policies of our organization. Further, some principles have standards to give more specifics and to help make our expectations clear.
If you need any assistance in understanding the Code of Conduct, the Compliance Program or need to discuss any concerns please contact:
Administrator, Compliance Liason
5547 N. Kenmore
Chicago, IL 60640
Compliance Hotline: 847-679-ABUSE
Administration and Application of this Code of Conduct
Bryn Mawr Care expects each person to follow the Principles and Standards in this document and to conduct the business and affairs of Bryn Mawr Care in a manner consistent with the general statement of principles set forth.
Failure to follow this Code of Conduct or the guidelines for behavior may lead to disciplinary action. This disciplinary action may range from oral correction to termination depending on the seriousness of the offense, prior actions and other factors that may be deemed relevant. In the event that an employee is covered by the terms of a collective bargaining agreement, discipline will be in accordance with the provisions of the collective bargaining agreement.
Any changes made to this Code of Conduct will be communicated to all employees.
Principle 1 – Legal Compliance
Bryn Mawr Care will strive to make certain all activity by or on behalf of the organization is in compliance with applicable laws, regulations and relevant guidance.
Standard 1.1- Fraud and Abuse
We expect that all employees will follow policies and laws prohibiting fraud and abuse. These laws expressly forbid : (1) payments in cash, gift or otherwise for referrals of Medicare or Medicaid residents directly, indirectly or disguised; (2) submitting of false, fraudulent or misleading bills to any governmental entity or third party payor. This includes bills for goods and or services not given or performed, bills which state the service differently than the service actually performed or bills which do not otherwise comply with the program or contract requirements.
Standard 1.2 – Discrimination
We believe that the fair and equal treatment of employees, residents and other persons is critical to fulfilling our vision and goals and that we must follow all laws that apply. It is our policy to recruit, hire, promote and terminate employees based on their own ability, achievement, experience and conduct and to admit residents to our facility without regard to race, color, religion, sex, sexual orientation, ethnic origin, age or disability. No form of harassment or discrimination of residents or employees will be tolerated on the basis of race, color, religion, sex, sexual orientation, ethnic origin, age, disability or any other classification prohibited by law. Each reported allegation of harassment or discrimination will be promptly investigated by the Corporate Compliance Committee.
Principle 2 – Business Ethics
Bryn Mawr Care’s commitment to the highest standards of business ethics requires that employees will accurately and honestly represent our facility. This principle requires honesty from individuals in the performance of their responsibilities and in communication with our attorneys, auditors and governmental agencies.
Principle 3 – Confidentiality
Bryn Mawr Care’s employees should strive to maintain the confidentiality of residents’ records and other business-type confidential information in accordance with all laws.
3.1 – Resident Information and HIPAA
All our employees have a responsibility for protecting the confidentiality of resident information. Employees must not reveal in any form of communication: (verbal, written, fax, electronic); any personal or confidential information such as diagnosis or treatments, etc., unless disclosure is supported by the applicable laws and/or the information is treated as required in the HIPPA regulations. If questions arise regarding confidential information or releasing information, employees should seek guidance from the Administrator.
3.2 – Business Information
Information, ideas and some business information are important aspects to an organization’s success. Information regarding our competitive position or business strategies, payment and reimbursement information and negotiations with employees or third parties should be protected and remain confidential.
3.3 – Personnel Actions / Decisions
Salary, benefit and other personal information relating to employees should be treated as confidential. All employees will use due care to prevent the release or sharing of information beyond those persons who may need such information to fulfill their job function. If questions arise regarding confidential information or releasing information, employees should seek guidance from the Administrator.
Principle 4 – Conflict of Interest
Officers and Covered Persons, which include: Compliance committee members and department heads, owe a special duty of undivided and unqualified loyalty, consistent with state and federal laws, to the organization. Persons holding such positions may not use their position for profit or gain or to assist others in profiting in any way at the expense of the organization.
4.1 – Services for Competitors / Vendors
Officers of our facility should divulge to the Corporate Compliance officer any -potential conflict of interest with regard to any other business entity they may be involved in initially when the Code is implemented, upon starting of new involvement and annually thereafter.
No covered persons should perform work or services for any competitor of ours or for any organization with which we do business with or which seeks to do business with us without written approval of the Corporate Compliance Liaison which will receive approval of the Corporate Compliance Committee.
Nor should any employee allow their name to be used in any fashion that would tend to indicate a business connection with other organizations without the written approval of the Corporate Compliance Liaison which will receive approval of the Corporate Compliance Committee.
4.2 – Participation on Board of Directors / Trustees
Covered persons must obtain approval from the Corporate Compliance Liaison which will receive approval of the Corporate Compliance Committee to serve as a member of the Board of Directors / Trustees of any organization whose interests may potentially or actually conflict with ours. Any questions regarding whether or not Board / Trustee participation might present a conflict of interest should be discussed with the Corporate Compliance Committee.
Once approved the covered person must disclose all Board / Trustee activities in a written Conflict of Interest disclosure statement that should be submitted to the Corporate Compliance Committee before such activity is undertaken, and again annually.
All fees or compensation (other than reimbursement for expenses from Board participation) that are received for Board services provided during normal work time may be required to be paid directly to Bryn Mawr Care.
Bryn Mawr Care reserves the right to prohibit membership on any Board of Directors / Trustees where in the judgment of the Compliance Committee such membership might conflict with our best interest.
Principle 5 – Business Relationships
Business transactions with vendors, contractors and other third parties should be transacted in accordance with state and federal laws free from offers or solicitation of gifts, favors or other improper inducements. The following standards below are to guide employees in determining the appropriateness of the listed activities or behaviors within our business, and relationships with vendors, providers, contractors, third party payors and governmental entities. It is our intent that this policy be viewed broadly to avoid conduct with even the appearance of improper activity. Any questions regarding whether or not a relationship might present a violation of this policy should be discussed with the Corporate Compliance Committee.
5.1 – Gifts and Gratuities
It is our desire to, at all times preserve and protect our reputation and to avoid the appearance of impropriety or wrong-doing.
A. Unsolicited gifts of nominal value may be accepted or given from/to existing or potential vendors but must be disclosed to the Corporate Compliance Committee using the form in Appendix l.
An unsolicited gift of nominal value is defined as a gift, cash or cash equivalent of market value of $50.00 or less per source, per occasion, however, the total per source may not exceed $100.00 in a calendar year. This includes:
B. Employees should not accept nor offer gifts, favors, services, entertainment or other things of value to the extent that decision-making or actions affecting Bryn Mawr Care might be influenced. Similarly, the offer or giving of money, services, gifts or other things of value with expectation of influencing the judgment or decision- making process of any purchaser, supplier, customer, governmental official or any other person is also prohibited.
C. Employees are prohibited from soliciting or accepting tips, gratuities or gifts from residents and or families.
5.2 – Workshops, Seminars and Training Sessions
Attendance at seminars, workshops and training sessions at a vendors’ expense outside of Illinois is permitted only with the written approval from the Corporate Compliance Liaison which will receive approval of the Corporate Compliance Committee.
5.3 – Contracting
All business relations with contractors must be conducted at arm’s length both in fact and in appearance and in compliance with the facility’s policies and procedures. Questions regarding particular relationships, etc. may be referred to the Compliance Committee.
5.4 – Business Inducements
Our employees should not seek to gain any unlawful advantage through the improper use of payments. The offering, giving, soliciting or receiving any form of bribe is prohibited.
From time to time appropriate commissions, rebates, discounts and allowances are customary and acceptable provided they are approved by the Corporate Compliance Officer. Any such payments must be reasonable in value, competitively justified, properly documented and made to the business entity to whom the original agreement or invoice was made or issued. Such payments should not be made to individuals. Any such payments where legally appropriate must be passed on to the appropriate governmental unit.
Principle 6 – Protection of Assets
All employees will strive to preserve and protect our assets by making prudent and effective use of our resources and properly and accurately reporting its financial condition. It is our intent to guide with this principle and the following standards our expectations as they relate to activities and behaviors which may impact our financial health.
6.1 – Financial Reporting
All financial reports, accounting records, expense accounts, time sheets and other documents must accurately, and clearly represent the facts or the true nature of a transaction to the preparers knowledge. Improper or fraudulent accounting, documentation or financial reporting is contrary to the policy of Bryn Mawr Care and may be in violation of applicable laws and therefore is prohibited.
6.2 – Travel and Entertainment
Travel and entertainment expenses should be consistent with the employee’s job responsibilities and the organization’s needs and resources. Employee are expected to exercise reasonable judgment Employees must also comply with our policies relating to travel and entertainment which require prior approval of the Administrator.
This Code of Conduct is part of the overall Corporate Compliance Program. All employees should be familiar with our Program. The program highlights our intent to ensure that all employees follow all applicable laws and regulations.
All employees are required to report their good faith belief of any violation of the Compliance Program, fraudulent activity, or applicable law. Bryn Mawr Care, at the request of the employee, will provide anonymity to the employee(s) who report violations to the extent possible under the circumstances. Bryn Mawr Care and its consulting facilities will investigate employee concerns and take necessary corrective action.
There will be no retaliation in the terms and conditions of employment as a result of such reporting. Employees will report their good faith belief of violations of the compliance program, fraudulent activity, or applicable laws either orally or in writing to their Supervisor, Administrator (Compliance Liaison), Compliance Committee member or Compliance Officer.
Mark Solomon, Compliance Officer
6840 N. Lincoln
Lincolnwood, IL 60712
Compliance Hotline: 847-679-ABUSE