WHO IS ACCREDITED?

Private Organization Accreditation

Southeastern Regional Mental Health, Developmental Disabilities and Substance Abuse Services is a Local Management Entity, covering the geographic areas of Bladen, Columbus, Robeson, and Scotland counties. SER ensures continuity of care to consumers through access to a quality of care system available 24/7/365 days a year through management of our network provider services.
read more >>

VOLUNTEER TESTIMONIAL

Barry Gourley

Volunteer Roles: Endorser; Peer Reviewer

It is an honor to be a COA volunteer. I’ve had a great opportunity to work with fabulous COA volunteers, I’ve grown professionally in the COA accreditation process and I’ve met some wonderful people across this nation who are working hard to help and support children and families.
read more>>

Purpose

The rights and dignity of clients are respected throughout the organization.

FOC
CR 2: Confidentiality and Privacy Protections

The organization protects the confidentiality of information about clients and assumes a protective role regarding the disclosure of confidential information.

Interpretation: The organization must carefully reconcile its policies, procedures, and practices with all applicable confidentiality laws and regulations including, but not limited to, laws and regulations governing information about youth involved with the juvenile justice system, mental health consumers, victims of domestic violence, drug and alcohol treatment, and HIV/AIDS.

The organization’s procedures must reconcile legal restrictions on the release of identifying information about clients with mandatory reporting and duty to warn requirements. Written procedures should include guidance to personnel in determining the degree of danger a person may pose to him or herself or to the community.

Adult Guardianship (AG) programs must have procedures in place to ensure the decision to release confidential information is made in an ethical manner. See AG 8.02 for more information on ethical decision-making. The level of client involvement in the decision to release confidential information will vary based on the court order and state law.

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CR 2 Practice standards.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the CR 2 Practice standards.
3
Practice requires significant improvement as noted in the ratings for the CR 2 Practice standard; and/or
  • One of the CR 2 Fundamental Practice Standards received a 3 or 4 rating.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CR 1 Practice standards; and/or
  • Both of the CR 2 Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Confidentiality policy and procedures
    • Sample release form for disclosure of confidential information
No On-Site Evidence
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals or families served
    • Review case records

  • FP
    CR 2.01

    The organization informs the client about circumstances when it may be legally or ethically permitted or required to release such information without his or her consent.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • There are a few instances where clients were not fully informed that the organization may have legal or ethical circumstances when confidential or private information may be released without consent, but corrective action was immediately implemented prior to the actual release of the private information.
    3
    Practice requires significant improvement; e.g.,
    • Written procedures do not provide sufficient guidance to personnel to reconcile when the organization may be legally or ethically permitted or required to release confidential or private information without prior notification of client.
    • There are instances where staff have released confidential or private information inappropriately.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; 
    • The organization has faced legal action because of inappropriate release of information.

  • CR 2.02

    When the organization receives a request for confidential information about a client, or when the release of confidential information is necessary for the provision of services, prior to releasing such information, the organization:

    1. determines if the reason to release information is valid;
    2. obtains the client’s informed, written authorization to release the information; and
    3. obtains informed, written authorization from a parent or legal guardian, as appropriate.

    Interpretation: In the context of this standard, “valid” means justifiable, legitimate, convincing, legally permissible, and in the best interest of the client.

    The organization obtains legal counsel regarding the confidentiality of records and the conditions under which they may be subpoenaed. Unless otherwise required by law, authorization to release confidential information is not necessary where the request for information is pursuant to a subpoena. The organization seeks additional legal counsel, as necessary, when others seek identifying information about an individual or family, or when the release of confidential information is necessary for the provision of services.

    When the client is a minor or an adult under the care of a guardian, the organization should follow any laws or regulations allowing or requiring the organization to obtain the authorization of clients’ parents or legal guardians.

    When permitted or required by law, regulation, or court order, confidential information may be released without the authorization of the client and legal guardian. However, the client and legal guardian should still be informed that the information will be released.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Written, informed consent is always obtained prior to releasing information, and there have been no instances where confidential information was inappropriately released, but procedures or practice could be strengthened or clarified.
    3
    Practice requires significant improvement; e.g.,
    • In a few rare instances, information was inappropriately released or informed consent not obtained.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • CR 2.03

    Informed, written consent is obtained from the client, or a legal guardian, prior to recording, photographing, or filming.

    Interpretation: When required by law, consent may not be necessary. However, it is still expected that the organization inform clients prior to recording, photographing, or filming.

    Interpretation: For Early Childhood Education (ECE) or Out-of-School Time Services (OST), it is not necessary to obtain consent each time children or youth may be recorded, photographed, or filmed; consent may be provided at enrollment and maintained in program records or files. Consents should be reviewed and updated annually.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Written, informed consent is always obtained prior to releasing information, and there have been no instances where confidential information was inappropriately released, but procedures or practice could be strengthened or clarified.
    3
    Practice requires significant improvement; e.g.,
    • In a few rare instances, information was inappropriately released or informed consent not obtained.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • FP
    CR 2.04

    The release form for disclosure of confidential information includes the following elements:

    1. the name of the person whose information will be released;
    2. the signature of the person whose information will be released, or the parent or legal guardian of a person who is unable to provide authorization;
    3. the specific information to be released;
    4. the purpose for which the information is to be used;
    5. the date the release takes effect;
    6. the date, event, or condition upon which the consent expires, not to exceed one year from when the release takes effect;
    7. the name of the person(s) or organization(s) that will receive the disclosed information;
    8. the name of the person or organization that is disclosing the confidential information; and
    9. a statement that the person or family may withdraw their authorization at any time except to the extent that action has already been taken.

    Interpretation: Blanket release forms signed by clients when service is initiated do not meet the requirements of this standard, except as put forth by federal regulation, for example, when making application to FEMA/DHS in a declared disaster.

    Interpretation: In relation to element (f), the expiration event or condition should relate to the individual or to the purpose of the use or disclosure. The date, event, or condition upon which the consent expires must ensure that the authorization will last no longer than reasonably necessary. When the release of information is required for ongoing service provision, all elements of the form must be reviewed and updated annually at minimum to ensure that consent continues to be informed and appropriate. 

    Interpretation: When a release form is used to authorize the exchange of information between multiple parties, the form must comply with all elements of the standard. All relevant parties must be authorized to disclose and receive the information specified, for the purpose indicated, in the consent.

    Interpretation: When permitted or required by law, regulation, or court order, confidential information may be released without the authorization of the person or legal guardian. In this case elements (b) and (i) will not apply. However, the organization should still inform the person and/or legal guardian that the information will be shared, as referenced in CR 2.01 and CR 2.02, and maintain documentation of the disclosure in the client’s file.

    Interpretation: In credit counseling organizations this standard applies in situations where a client specifically requests release of information to a third party, such as a letter of reference regarding payment history, or in instances when a program specific release does not exist.  Debt management agreements or releases signed at the initiation of a debt management program allow for information sharing with all creditors included in the program or added to the program for the duration of service, unless state laws indicate otherwise.

    Interpretation: Release forms may also include a statement regarding the impact, if any, of refusing to sign the authorization, as well as rules regarding re-disclosure of information in accordance with applicable federal and state laws.   
     

    Research Note: Research suggests that organizations with clear confidentiality policies and consent form requirements have increased collaboration among providers, clients, and families. This increased collaboration can have a positive impact on the relationship between providers and family members and further open lines of communication for the future.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Consent forms are always completed and signed, but in a few instances information related to elements (c) or (d) is vague.
    3
    Practice requires significant improvement; e.g.,
    • Consent is always obtained and forms are signed, but a significant number of consent forms
      • Have missing or inadequately addressed components; or
      • Are overly broad or non-specific.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • Information has been released without proper consent; or
    • Consent forms consistently do not meet one or more of the requirements of the standard; or
    • Are routinely improperly completed; or
    • There are instances of incomplete but signed consent forms in case records; or
    • The organization uses blanket consent forms.

  • CR 2.05

    The organization offers a copy of the signed form to the person or family authorizing the disclosure of confidential information, and places a copy in the case record.

    Interpretation: When there are concerns about the individual’s capacity to understand the confidential nature of the document, such as when the individual has been deemed incapacitated by the court, it may be inappropriate to provide the individual with a copy of the release form. Instead, the worker should include a copy of the release form in the case record and document reasons why the form was not provided.

    Interpretation: A copy of the completed release form should be offered to the person, and placed in the case record, even when it is permissible by law to release confidential information without the person’s authorization and signature.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • The standard is met in practice, but procedures need minor clarification; or
    • In a few instances the information was not provided.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are clearly inadequate; and/or
    • In a significant number of cases the information was not provided or there is no documentation that clients were offered a copy.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
Copyright © 2018 Council on Accreditation. All Rights Reserved.  Privacy Policy and Terms of Use