Hospice in an ALF and HIPAA

[Race Mom, ASN, RN]

Our hospice is moving to EMR and the facilities are given access to our pt electronic chart (until full implementation we print and fax ALL clinical notes from RN, LCSW, and SCP). I feel this could open us up for a HIPAA violation. I could be completely wrong, but the following just doesn't sound like we are protecting our pt's FAMILY (as hospice, our care is for the whole family, not just the patient).

I have a pt that has a dx process that the spouse could no longer manage at home. This is a young pt. This pt also has a young child. The pt was moved to an ALF very recently.

My concerns:

Child has a volunteer from our hospice, that volunteers for HIM, not pt

Social Work and Spiritual Care will split their visits between pt, spouse, and child.

All notes from these disciplines are "available" for the facility to look at through EMR.

I find that this violates the family's HIPAA rights to their privacy of issues they may be working through, whether d/t pt condition or other issues.

For example: let's just pretend...(seriously)

Spouse confides in social worker that he had multiple affairs during his marriage and he is struggling with it....or...he has met someone new now that spouse is in facility...or...he is suicidal....or he has found out he has been diagnosed with (anything).

Son confides in social worker or volunteer that he is being bullied at school, or that he became sexually active, or that he smoked pot...

(seriously, I made all these examples up)

What business is that of the facility? How will that help them accomplish caring for this pt that needs their skilled services?

In my opinion, it violates the family's right to privacy and their right to protected health information. I was told today that the facility should be getting all notes from all disciplines. Because I feel so strongly that I feel the facility has no right to read these notes as it does not help them provide care to the hospice patient but allows them to read the "novel" of the family.

Please let me know what the rule is on this. I would like to make sure I am following HIPAA and that my company is too.

[CrunchRN, ADN, RN]

I agree. Although I do not know the answer. At the least it is a huge invasion of their privacy.

[klone, MSN, RN]

Okay, asked my husband, the hospice guru (he really is, he's a Rainman on CMS compliance):

What is the ALF's charting process? Do they have paper charts? If so (and he said he has never seen an ALF that had EMR), then the hospice will make notes in the patient's chart at the ALF. Or, they will print out applicable nursing notes or notes on physician face-to-face- visits, that the ALF can put in their chart on the patient.

He is also asking, how does the ALF have access to the hospice's EMR? It's separate from the facility and they shouldn't be able to have access to it.

[Race Mom, ASN, RN]

They have paper charts and do some things on the computer (seems like mostly vitals). I am not aware of exactly how they have secured the access, but they have access to our intranet, must put in their credentials, and then can receive limited stuff on only the pts they share with us. I was told yesterday that I am supposed to be printing off and giving them ALL clinical notes, from all disciplines, even if it is just a short note about communication with the spouse or family. They (my hospice) was concerned that if there is ever an audit, that it could be an issue that they don't have all the notes.

I just don't get why they need all the notes on EVERYTHING. We are a small but large hospice and the owners definitely have invested in compliance as we have compliance team, IT team, a staff pharmacist, etc. We really are on top of things and run very well.

[toomuchbaloney]

The CoPs describe a minimum amount of communication and access to PHI that must be shared by hospice patients residing in SNFs. When hospices start printing the required documentation for the facilities the sheer volume quickly became a burden to everyone. Providing them view only access to parts of the chart via EMR in the facility is a good idea I think.

[krisiepoo]

I use to do counseling and I would NEVER write any of that in a chart... I used to have "official" notes and my "unofficial" notes that never made it into a file because it was no one else's business. SW can write "spouse struggling with marriage" in the official chart, which would be true for just about any marriage going through something like this.

[MunoRN, RN]

EMR's are required to have a security filter for mental health/behavioral health notes, so it should be possible to block access to this documentation to certain caregivers. Most EMR's go well above that requirement with their security levels.

Depending on the level of care being provided at the ALF, which is typically very minimal but can often become more acute as the patients need require, I'm not sure that it's necessarily true that the information the hospice nurse needs to care for the patient is all that different from what a facility nurse might need. In other words, why does the hospice nurse need all the drama background either?

[Race Mom, ASN, RN]

Hospice cares for the family, not just the patient. I totally messed up by asking about ALF, as my concern is a pt in a SNF, but it does carry over into those in ALF's. There just seems to be a lot of charting done (mainly other disciplines than nursing) that are family centered (legal paperwork, etc) that have nothing to do with the pt care, but is charted to show it was done for the family.

[MunoRN, RN]

Hospice cares for the family, not just the patient. I totally messed up by asking about ALF, as my concern is a pt in a SNF, but it does carry over into those in ALF's. There just seems to be a lot of charting done (mainly other disciplines than nursing) that are family centered (legal paperwork, etc) that have nothing to do with the pt care, but is charted to show it was done for the family.

Nurses in SNF's don't care for the patient as part of a larger social group? I doubt this is what you meant, but you seem to be implying that the nurses at the SNF are only there to do tasks, not provide nursing care, as opposed to the hospice nurse.

[ktwlpn, LPN]

Nurses in SNF's don't care for the patient as part of a larger social group? I doubt this is what you meant, but you seem to be implying that the nurses at the SNF are only there to do tasks, not provide nursing care, as opposed to the hospice nurse.

Exactly-the staff in the SNF are caring for this patient and supporting the family the other,what,22 hours per day hospice is not at the bedside? They are all part of the team, they are following the hospice directed plan of care, they need all of the information available. Hospice provides support to the family and bereavement support after the loss-they are not going to be fixing a train wreck (as you suggested in you hypotheticals) I think you got a little too focused in those scenarios. For instance hospice will lead the team in offering support to the spouse with "a complicated grieving pattern" .Enough said. If he is diagnosed with something they are not obligated to see he seeks out appropriate care or provide marriage counseling if he hooks up with another SNFer.As for the minor child I don't know what the oligations to report are, someone else can address that. AND the SNF has their own social worker following the case, too...

[Race Mom, ASN, RN]

Wowsers, certainly didn't mean to have that read into so wrong. Definitely sorry if I offended you two. I re-read my post to see where I mentioned that SNF nurses only did tasks. I don't feel that I did write that since I don't feel this way. As a matter of fact, this pt is very difficult and I feel for the consumption of time this pt takes to care for each day. Although I have had major problems with the two facilities I work with NOT following some very, very important parts of the hospice POC. I also never said that hospice was going to "fix" the train wrecks or provide marital counseling. We do, however, help them with grief before and after death.

Ugh, never expected to get such negative feedback from a HIPAA question. It is so frustrating and takes a little out of my "cup" for my passion for what I do. Again, sorry I offended you guys.

[klone, MSN, RN]

Woogy, fwiw, as someone with no dog in this race, I don't think you said anything wrong. IMO, Muno read into your post things you did not say or imply, and chose to read offense where there was none.