Confidentiality Policy

CONFIDENTIALITY POLICY

revised 11/20/23

 

Confidential Information and Parties Involved

A client is defined as anyone seeking services for any of the Housing Help of Lenawee (H2L) programs, and the children of that person.

Any and all information including the name of the client and other personal information is subject to the terms of this Confidentiality Policy.

Staff, volunteers and interns of H2L are all bound by this Confidentiality Policy.  H2L staff members are in a position of trust and must not divulge information contained in the client case file, except in accordance with this policy.  H2L staff may not use their position or confidential information acquired in the course of official duties to further their own personal interests or to secure privileges or exemptions for themselves.

Staff, volunteers, and interns of H2L have a duty to keep client information confidential throughout their term as a staff/volunteer/intern as well as after their employment or volunteer/intern status ends.

Although H2L owns the client case file created, the client retains the right to see the case file and to determine who, beyond H2L, is allowed to see the information in the case file.

Confidentiality Policy Disclosure

Clients are informed of this Confidentiality Policy via posting in the H2L lobby and during intake to the emergency shelter or transitional housing program.  In addition, H2L’s statement and position on child protection and violent behavior is posted in the emergency shelter and transitional housing program agreements.

Case File Documentation and Record Keeping

A client’s case file is to contain only the information which is:

  • required by funding sources;
  • required to determine eligibility for services; and
  • required to demonstrate provision of service.

 

Documentation in client case files is to be organized in a similar manner per program and client case notes must be dated.

The following information is NOT appropriate for a client case file:

  • creative writing;
  • any notations regarding a client reporting dates, times or sequence of events in an abusive incident;
  • papers for safekeeping; and
  • identifying reference to another client.

 

Only H2L staff can make entries in the client case file. Staff may record any interaction of a volunteer or intern with the client and /or client contact in the case notes of the client file.  Only H2L staff can enter data into MSHMIS.

Entries in a client case file that are inconsistent with this Confidentiality Policy should be corrected or deleted. Corrections and deletions may be made in a client case file using the following procedure:  entry is blacked out with permanent marker and followed by the statement, “Inconsistent with record-keeping policy.”  This notation is signed and dated by the H2L staff making the correction.

A client, after having the opportunity to review his/her file, may request a correction or removal of information that he/she believes to be inaccurate, irrelevant, outdated or incomplete. This request will be reviewed by the Executive Director. If the correction is deemed warranted, it will be made by the Case Manager. If not, the Case Manager will communicate this decision to the client who then has the option of including a response statement in his/her case file.

The Executive Director is the custodian of files. In the event of a prolonged absence of the Executive Director, the Board of Directors will choose an alternate to serve in this position.

Active and closed client case files are maintained as follows:

  • Active client case files are kept in the Case Manager’s office and in an area not visible by other clients or visitors. The office is locked at night.
  • Closed case files are stored in locking file cabinets located in the File Room, which is locked at night.
  • Client case files are maintained for as long as indicated by funding requirements.
  • Client case files are destroyed after that time.
  • Client files are not to be removed from H2L premises without approval from the Executive Director.
  • MSHMIS entry is not to be completed outside of the H2L office.

 

Access to Client Case Files

All H2L staff has general access to client case files. H2L volunteers or interns may have limited access to case files in certain circumstances.  Any volunteer or intern provided access to client case files have signed an agreement stating that as a volunteer/intern with H2L they will be held to confidentiality for not releasing any information, including names of clients in any of our programs that they may meet or see.

A client may request to review his/her file at any time but must be done under the direction of a H2L Case Manager or Executive Director.  If a client requests access when a Case Manager or the Executive Director is unavailable, the client will be asked to wait until that staff can be located.

Communication with Third Parties

Information is shared with third parties only with a “Release of Information” form signed by the client.  Information released to third parties must be in the best interest of the client and for the provision of H2L services or other services to include housing and self-sufficiency purposes.

A “Release of Information” form shall include:

  • the name of the individual/organization to whom the information will be released;
  • the time period for which the release is effective, not to exceed one (1) year;
  • the scope and nature of information to be released; and
  • a place for the client to sign and date the release

 

An emergency verbal release of information is allowed in the event that the health or safety of the client or the client’s child would be jeopardized by failure to release the information. The verbal consent should be documented in the client’s case notes and should be followed up with a signed “Release of Information” form as soon as possible.

A release of information may be revoked by the client in writing at any time. However, the client may not seek to include any information already released under the terms of the original consent.

When a release of information is initiated by another agency or individual, the client will need to sign a H2L release of information as well.

Program Initiated Disclosure

Clients in the emergency shelter and transitional housing programs are asked to provide the name of a contact person to be notified in the event of an emergency. A release of information should be signed for this person.

Per the Child Protection Law (noted on the last page of this policy), H2L staff are required to report any abuse or neglect of a child that they witness.  In the event abuse or neglect is suspected but not witnessed, the Executive Director or acting supervisor will make the determination of whether a report will be filed.

All clients are informed upon intake that information regarding such abuse or neglect will be released to Children’s Protective Services with or without the client’s consent. Only that information which is pertinent to the abuse and neglect is to be released.

H2L staff will report to the proper authorities when a client presents a credible threat of harm to himself/herself or others. Clients are informed at intake of this exclusion to their right to confidentiality.

H2L staff shall be authorized to make a police report if a client commits a violent crime or threatens violence against another H2L client, staff, volunteer or intern. In the event that a police report is made, the release of information is limited to what is necessary and relevant to the report.

Confidentiality is to be maintained upon the death of a client. If there is a need to release any information that has been conveyed by a client through confidential communication or contained in files, the authority to release that information lies with the Executive Director who will determine whether the need for the release of information outweighs the responsibility to protect the client’s confidentiality. The determining factors to be considered are:

  • if disclosure would serve the best interest of the deceased client;
  • if disclosure is necessary to protect the interest or safety of specific parties (i.e. children, parents);
  • how disclosure would affect the interests of justice and protection of the community as a whole; and
  • if information has been formally requested by the prosecutor or an attorney representing the victim’s interests

 

If it is determined that information should be released, H2L will attempt to gain the support of the executor or personal representative of the deceased.

Subpoenas & Warrants

H2L staff shall not be authorized to accept a subpoena on another’s behalf. If the subpoena is for records or is intended for another H2L staff member who is not on the premises, the process server should be directed to the Executive Director or acting supervisor.

H2L staff shall not be authorized to provide any information on clients but should provide a copy of the Confidentiality Policy and the name of the Executive Director.

If a law enforcement representative comes to H2L with a warrant, staff will contact the Executive Director or acting supervisor immediately, and ask the officer to wait until that person can respond.

Breach of Confidentiality Policy

Breach of Confidentiality is defined as – the disclosure of information, intentionally or unintentionally, to an individual who is not entitled to that information. The disclosure of confidential information will be considered sufficient cause for progressive discipline as outlined in employee handbook.

  1. H2L must notify affected individuals following the discovery of a breach of unsecured confidential information
  2. This notice must be provided in written form by first class mail, or alternately by email if the affected individual has agreed to receive such notices electronically
  3. These notices must be provided without unreasonable delay and in no case later than 60 days following the discovery of a breach and must include, to the extent possible, a brief description of the breach, a description of the types of information that were involved in the breach, the steps affected individuals should take to protect themselves from potential harm, a brief description of what the covered entity is doing to investigate the breach, mitigate the harm, and prevent further breaches.

 

CHILD PROTECTION LAW

Act 238 of 1975

 

An ACT to require the reporting of child abuse and neglect by certain persons; to permit the reporting of child abuse and neglect by all persons; to provide for the protection of children who are abused or neglected; to authorize limited detainment in protective custody; to authorize medical examinations; to prescribe the powers and duties of the state department of social services to prevent child abuse and neglect; to prescribe certain powers and duties of local law enforcement agencies; to safeguard and enhance the welfare of children and preserve family life; to provide for the appointment of legal counsel; to provide for the abrogation of privileged communications; to provide civil and criminal immunity for certain persons; to provide rules of evidence in certain cases; to provide for confidentiality of records; to provide for the expungement of certain records; to prescribe penalties; and to repeal certain acts and parts of acts.

 

CHILD PROTECTION – Child Abuse will not be tolerated.

Housing Help of Lenawee is required by law to report any neglect or abuse, observed or suspected, of your child/children either by you or other persons.   This includes:

* Physical, Mental or Verbal abuse     * School Truancy     * Illegal behavior

VIOLENT BEHAVIOR – Housing Help of Lenawee does not allow any type of violent behavior on the premises of the H2L office, Toledo Street Emergency Shelter, Church Street Family Shelter, or Transitional Housing units.  Any violent behavior observed will be reported to the local law enforcement.