To find out how your protected health information may be used or disclosed, we invite you to read the Notice of Privacy Practices (NOPP). This document also describes your rights with regard to this information. If you have further questions about the NOPP, please contact our Privacy Official at (949) 240‐7200.
Our Code of Ethics
This Code of Ethics is based on our Core Values and will be reviewed at least every two years and revised as necessary in response to issues which arise in the health care industry, changes in accreditation, legal and/or regulatory requirements and recommendations which may arise from resolution of ethical issues.
We are committed to ensuring confidentiality of records and related information for all patients, employees and hospital business. Any breach of confidentiality represents a failure to meet the professional and ethical standards expected, and constitutes a violation of this Ethics Policy. A full confidentiality and privacy statement is received and accepted by each employee as part of the employee handbook.
Quality of Care
We ensure that our employees provide appropriate, quality care by:
- Individualizing care for each patient/resident/client with care plans that document the reason(s) for the level of care, goals and objectives, interventions and participation by appropriate professionals, and which are reviewed and revised according to each patient/resident/client's needs.
- Using adequate numbers of appropriately trained staff to implement each patient/resident/client's care plan.
- Supporting our staff in monitoring quality, utilization of resources and the appropriateness of the care plans.
- Providing our employees with adequate resources to do their work.
- Evaluating technological advancements occurring in the marketplace and allocating resources for the purchase of appropriate equipment.
We ensure appropriate care for all patients/residents/clients,regardless of race, gender, age, religion, national origin, disability,sexual preference, ability to pay or type of health plan coverage.
We develop and implement policies and procedures to protect patient/resident/client rights in the delivery of care. These policies and procedures are located in administrative, operations and/or patient/resident/client are manuals and include rights, informed consent, advance directives, and more.We support and facilitate patient/resident/client rights to access guardianship, advocacy, conservator ship by providing and receiving requested information.
If You Have a Concern
You have the right to file a complaint/grievance. If you want to file a complaint/grievance with Silverado, you may do so by writing or calling:
Privacy & Ethics Officer
Risk Management Department
6400 Oak Canyon, Suite 200
Irvine, California 92618
You may file a complaint with the state Department of Health Services regardless of whether you use Silverado’s grievance process. The state Department of Health Service’s phone number and address is:
Department of Health Services
5555 Ferguson Drive, Room320
Commerce, California 90022
We communicate our billing policies to all our patients/residents/clients prior to, or, at the time of admission or service.We bill our patients/residents/clients for services rendered and provide itemized bills free of charge upon request.Our patient/resident/client business office responds to patient/resident/client questions in a timely and courteous manner.
We perform an internal audit annually to ensure the accuracy of our bills. Adjustments are made to correct any over or under billings.
We are committed to providing patient/resident/client health education,to encouraging and empowering our community to adopt healthy lifestyles, and to helping individuals and families.
Marketing and Advertising
We adhere to principles of truth, accuracy, and fairness in all marketing and advertising. We will not distort the truth about services or products provided by Silverado, nor will we attack or disparage another provider, whether by name or implication, in any marketing or advertising efforts. We may feature our outstanding services or offer factual evidence of quality of care, but will not claim superiority where it cannot be substantiated.
We treat our vendors fairly and maintain impartiality in our relationships. We do not allow our friendships with our vendors, or others with whom we may do business in the future,to affect our business decisions.
Charitable gifts or contributions from vendors are not required, and have no bearing upon their actual or potential business relationship with us.
We are committed to hiring competent individuals who support our Core Values. For our employees, we provide:
- Continuous educational opportunities,to ensure their competency and knowledge.
- A work environment in which ethical concerns may be raised and openly discussed without fear of retribution or retaliation.
Employees are expected to action an ethical manner at all times. They are expected to:
- Adhere to and uphold county,state and federal laws and regulations.
- Shun harassment, dishonesty or theft.
- Protect assets belonging to patients, employees and others(including themselves) against loss, theft and/or misuse.
- Report incidents which they believe may be unethical to their supervisor or to the Director of the Human Resources Department. Supervisors are responsible for notifying their Department Director. Directors are responsible for notifying their Vice President.
All employees are expected to adhere to our Core Values and Code of Ethics, regardless of position, personal preferences, inconveniences or business pressures. Violations of the Code of Ethics should be promptly reported, reviewed and investigated. Those who violate these codes or knowingly fail to report violations may be subject to disciplinary action, up to and including
termination of employment.
Our employees are required to adhere to and uphold county,state and federal laws and regulations.
Conflict of Interest
We avoid real or perceived conflicts of interest to ensure objectivity and maintain individual and corporate integrity. Board members, administration, employees(and their immediate family members) shall not:
- Hold any material financial interests in companies or organizations that do business or are seeking to do business with Silverado, without full disclosure.
- Accept cash payments or personal gifts of more than nominal value from companies or organizations doing business with us.
- Be directly or indirectly responsible for hiring or supervising an immediate family member.
If a conflict of interest exists, employees must report it to the appropriate management. The Chief Administrative Officer and Risk Management shall be responsible for taking appropriate action to eliminate any conflict of interest.
Effective on September 1, 2013, Silverado will not collect any personally identifiable information (e.g. name, phone number, e‐mail address) without your knowledge. Like most organizations, we regularly monitor trends, traffic patterns, number of visits, etc. on our site, so we can better meet the needs of our customers. This does not entail collecting any personally identifiable information.
Any online job applications we receive are shared only within our health system for the purpose of hiring and recruiting. Under no circumstances is any information contained therein shared with or sold to anyone outside of Silverado. If you have set up a user profile, you may update your online application at any time using your established username and password. Applications are stored in our database for 24 months from the time of initial creation.
If you e‐mail us via our website, your message may be routed within Silverado for the purpose of responding to your question or request. In addition, a hard copy of your message may be retained for up to one year for the purpose of quality improvement. Under no circumstances will your e‐mail address be shared with or sold to anyone outside Silverado.
This website is solely owned and operated by Silverado or designated business associates. No revenue, including advertising revenue, is received from any other source. If you have questions about this Website Policy or any other aspect of our website, please contact us at (949) 240‐ 7200.
NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE: September 1, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
USE AND DISCLOSURE OF HEALTH INFORMATION ‐ SILVERADO may use your health information (information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and the Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under HITECH Act and the GINA Act and Other Modification to HIPAA Rules of 2013) for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Silverado has established a HIPAA Policy and Procedure Manual to guard against unnecessary disclosure of your personal health information.
A SUMMARY OF THE CIRCUMSTANCES AND PURPOSES UNDER WHICH THE LAW PERMITS YOUR PERSONAL HEALTH INFORMATION TO BE USED AND DISCLOSED ‐
To Provide Treatment. Silverado may use your personal health information to coordinate care within the Community or At Home and with others who are involved in your care, such as your attending physician, members of Silverado’s interdisciplinary team and other health care professionals who have agreed to assist Silverado in coordinating care. Silverado also may disclose your health care information to individuals outside of Silverado involved in your care including family members, caregivers, clergy who you have designated, pharmacists, suppliers of medical equipment or other health care professionals.
To Obtain Payment. Silverado may use and disclose your health information to collect payment from third parties for the care you receive while at Silverado. Your health information may be used and disclosed on invoices, correspondence and other communications with your health care insurer. Silverado also may need to obtain prior approval from your insurer and may need to use and disclose health information to explain to the insurer your need for care and the services that will be provided to you. Silverado will respect the right to restrict certain disclosure to third party if you opt to pay for services in full and notify Silverado in writing of your right to restrict disclosure of your health information to such third party.
To Conduct Health Care Operations. Silverado may use and disclose health information for its own operations in order to facilitate the function of Silverado and as necessary to provide quality care to all of Silverado’s patients/residents/clients.
For Marketing Activities: Silverado will request separate consent for use any personal health information or patient’s images to be used for marketing activities.
For Fundraising Activities: Silverado will request separate consent for use of any personal health information in fundraising activities.
For Appointment Reminders. Silverado may use and disclose your personal health information to contact you as a reminder that you have an appointment for a visit.
For Treatment Alternatives. Silverado may use and disclose your personal health information to tell you about or recommend possible treatment options or alternatives.
A SUMMARY OF THE CIRCUMSTANCES AND PURPOSES UNDER WHICH YOUR PERSONAL HEALTH INFORMATION MAY ALSO BE USED AND DISCLOSED WITHOUT YOUR PRIOR AUTHORIZATION OR CONSENT, UNLESS SUCH DISCLOSURE IS FURTHER RESTRICTED OR LIMITED BY CALIFORNIA LAW ‐
When Legally Required. Silverado will disclose your personal health information when it is required to do so by any Federal, State or local law.
When There Are Risks to Public Health. Silverado may disclose your personal health information for public activities and purposes.
To Report Abuse, Neglect, or Domestic Violence. Silverado is allowed to notify government authorities if Silverado believes a patient is the victim of abuse, neglect or domestic violence. Silverado will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.
To Conduct Health Oversight Activities. Silverado may disclose your health information to a health regulator for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Silverado, however, may not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.
In Connection With Judicial and Administrative Proceedings. Silverado may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when Silverado makes reasonable efforts to either notify you about the request or to obtain an order protecting your personal health information.
For Law Enforcement Purposes. As permitted or required by State law, Silverado may disclose your health information to a law enforcement official for certain law enforcement purposes.
To Coroners and Medical Examiners. Silverado may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.
To Funeral Directors. Silverado may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, Silverado may disclose your health information prior to and in reasonable anticipation of your death.
For Organ, Eye or Tissue Donation. Silverado may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.
For Research Purposes. Silverado may, under very select circumstances, use your health information for research. Before Silverado discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.
- In the Event of a Serious Threat to Health or Safety. Silverado may, consistent with applicable law and ethical standards of conduct, disclose your health information if Silverado, in good Notice of Privacy Practice faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
- For Specified Government Functions. In certain circumstances, the Federal regulations authorize Silverado to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.
- For Worker's Compensation. Silverado may release your health information for worker's compensation or similar programs.
A SUMMARY STATEMENT OF THE CIRCUMSTANCES UNDER WHICH YOUR AUTHORIZATION IS NEEDED TO USE OR DISCLOSE HEALTH INFORMATION ‐ Except as described and stated above, Silverado will not disclose your personal health information other than with your written authorization. If you or your representative authorize Silverado to use or disclose your health information, you may revoke that authorization in writing at any time. Additionally, Silverado will not sell any of your health information under any circumstance.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION ‐ You have the following rights regarding your health information that Silverado maintains:
Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Silverado’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Silverado is not required to agree to your request. If you wish to make a request for restrictions, please contact the Privacy Officer. Silverado will restrict access to psychotherapy notes unless written permission is granted by you.
Right to Receive Confidential Communications. You have the right to request that Silverado communicate with you in a certain way. For example, you may ask that Silverado only conduct communications pertaining to your health information with you privately with no other family members present. However, Silverado cannot grant your request if you are under the care and control of a responsible party, conservator, or guardian. If you wish to receive confidential communications, please contact the Privacy Officer. Silverado will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
Right to Inspect and Copy your Health Information. You have the right to inspect and copy your health information, including billing records. A written and signed request to inspect and copy records which specifically notes the type of records, designated recipient, receiving address, and in what specific format (Paper or Electronic) containing your health information may be made to the Privacy Officer. If you request your records electronically please note transmission to an unsecure email address there is a risk of breach due to un‐encryption status of the health information. Your request will be provided within thirty (30) days of receipt of your request. Silverado may request an additional thirty (30) days extension for circumstance of off‐site storage. Silverado may charge a reasonable fee for copying and assembling costs associated with your request.
Right to Amend Health Care Information. You or your representative have the right to request that Silverado amend your records if you believe that your health information is incorrect or incomplete. That request may be made as long as the information is maintained by Silverado. A request for an amendment of records must be made in writing to the Privacy Officer. Silverado may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by Silverado, if the records you are Notice of Privacy Practice requesting are not part of Silverado’s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Silverado, the records containing your health information are accurate and complete.
Right to an Accounting. You or your representative have the right to request an accounting of disclosures of your health information made by Silverado for certain reasons, including reasons related to public purposes authorized by law and certain research. The request for an accounting must be made in writing to the Privacy Officer. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. Silverado will provide the first accounting you request during any12‐month period without charge. Subsequent accounting requests may be subject to a reasonable cost‐based fee.
Right to Notice of Breach. You or your representative have a right to be notified by Silverado in writing of a breach of unsecure protected health information. Silverado will notify you in writing within sixty (60) days of breach discovery date.
Right to a Paper Copy of This Notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact the Privacy Officer.
DUTIES OF SILVERADO ‐ Silverado is required by law to maintain the privacy of your personal health information and to provide to you and your representative this Notice of Silverado’s duties and privacy practices. Silverado is required to abide by the terms of this Notice as may be amended from time‐to‐ time. Silverado reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If Silverado changes its Notice, Silverado will provide a copy of the revised Notice to you or your appointed representative.
COMPLAINTS ‐ You or your personal representative have the right to express complaints to Silverado
and to the Secretary of DHHS – the Department of Health and Human Services at (800) 368‐1019 TDD toll‐free (800) 537‐7697 http://www.hhs.gov/ocr/privacy/hipaa/complaints/ if you or your representative believes that your privacy rights have been violated. Any complaints to Silverado should be made in writing to Silverado Privacy Officer. Silverado encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
CONTACT PERSON ‐ Silverado has designated a Privacy Officer as its contact person for all issues regarding patient privacy, personal health information, and your rights under the Federal privacy standards. You may contact the Privacy & Ethics Officer, Frank Russo, at (949) 240‐7200.
Illinois Biometric Data Defined
In Illinois, biometric data includes “biometric identifiers” and “biometric information” as defined in the Illinois Biometric Information Privacy Act, 740 ILCS § 14/1, et seq.(“BIPA”). “Biometric identifier” means a retina or iris scan, fingerprint, voiceprint, or scan of hand or face geometry.
“Biometric information” means any information, regardless of how it is captured, converted, stored, or shared, based on an individual’s biometric identifier used to identify an individual.
Purpose for Collection of Biometric Data
Silverado, its vendors, and/or the licensor of Silverado’s time and attendance software and systems collect, store, and use biometric data that may be covered by the definitions of BIPA because Silverado uses a biometric timekeeping system. This data is collected in the ordinary course of business and used for purposes including identifying associates, documenting clock in and clock out times and locations, and fraud prevention in timekeeping and the payroll process.
Generally speaking, a biometric timekeeping system is a computer-based system that scans an associate’s finger or face for purposes of identification. The computer system extracts unique data points and creates a unique mathematical representation used to verify the associate’s identity, for example, when the associate arrives at or departs from the workplace.
Disclosure and Authorization
Silverado will protect and store its associates’ biometric data in accordance with BIPA and applicable law.
Silverado, its vendors, and/or the licensor of the Silverado’s time and attendance software will not sell, lease, trade, or otherwise profit from associate’s biometric data; provided, however, that Silverado’s vendors and the licensor of Silverado’s time and attendance software may be paid for products or services used by Silverado that utilize such biometric data for the timekeeping and payroll process.
Silverado will not disclose or disseminate biometric data to anyone other than its vendors and the licensor of Silverado’s time and attendance software providing products and services using biometric data without/unless:
- Obtaining written associate consent to such disclosure or dissemination;
- The disclosed data completes a financial transaction requested or authorized by the associate;
- Disclosure is required by state or federal law or municipal ordinance; or
- Disclosure is required pursuant to a valid warrant or subpoena issued by a court of competent jurisdiction.
Silverado shall retain associate biometric data only until, and shall request that its vendors and the licensor of Silverado’s time and attendance software permanently destroy such data when, the first of the following occurs, unless the data is otherwise required to be retained by applicable law:
- The initial purpose for collecting or obtaining such biometric data has been satisfied, such as the termination of the associate’s employment with Silverado or the associate moves to a role within Silverado for which the biometric data is not used; or
- Within 3 years of the associate's last interaction with Silverado.
Silverado shall use a reasonable standard of care to store, transmit and protect from disclosure any biometric data collected. Such storage, transmission, and protection from disclosure shall be performed in a manner that is the same as or more protective than the manner in which Silverado stores, transmits and protects from disclosure other confidential and sensitive information, including personal information that can be used to uniquely identify an individual or an individual’s account or property, such as genetic markers, genetic testing information, account numbers, PINs, driver’s license numbers and social security numbers.
Silverado encourages associates to ask any questions they have about this policy.