PHIPA

POLICY

The facility supports and reflects Sifton Properties Limited (SPL) privacy initiatives and policy development under the direction of Senior Management, the Privacy Officers, and the Steering Committee formed for this purpose. The ultimate goal is to protect people's right of privacy, to educate staff and residents on their rights of privacy, and to appropriately conform to legislation affecting privacy. To this end, a policy statement has been developed for both staff and residents.

DEFINITIONS

Attorney for Personal Care: means an attorney under a power of attorney for personal care made in accordance with the Substitute Decisions Act, 1992, pursuant to the Personal Health Information Protection Act, 2004, S.O. 2004, c. 3 (hereinafter referred to as “PHIPA”).

Attorney for Property: means an attorney under a continuing power of attorney for property made in accordance with the Substitute Decisions Act, 1992; pursuant to PHIPA.

Circle of Care: means a person or organization, whether a health information custodian or non-health information custodian within the meaning of PHIPA, that is directly or indirectly involved in the provision of care of the resident and the resident has provided express or implied consent to such provision of care by the person or organization.

Confidential Information: means all information, other than personal and personal health information, regarding a client, staff person, volunteer or the organization, that is seen, heard, obtained or observed.

Health Information Agent: in relation to a health information custodian, means a person that, with the authorization of the custodian, acts for or on behalf of the custodian in respect of personal health information for the purposes of the custodian, and not the agent's own purposes, whether or not the agent has the authority to bind the custodian, whether or not the agent is employed by the custodian and whether or not the agent is being remunerated; pursuant to PHIPA.

Health Information Custodian: (hereinafter referred to as “HIC”) a person or organization described in one of the following paragraphs who has custody or control of personal health information as a result of or in connection with performing the person's or organization's powers or duties or the work described in the paragraph, if any:

  1. A health care practitioner or a person who operates a group practice of health care practitioners.

  2. A service provider within the meaning of the Long-Term Care Act, 1994 who provides a community service to which that Act applies.

  3. A community care access corporation within the meaning of the Community Care Access Corporations Act, 2001.

  4. A person who operates one of the following facilities, programs or services:

    1. A hospital within the meaning of the Public Hospitals Act, a private hospital within the meaning of the Private Hospitals Act, a psychiatric facility within the meaning of the Mental Health Act, an institution within the meaning of the Mental Hospitals Act or an independent health facility within the meaning of the Independent Health Facilities Act.

    2. An approved charitable home for the aged within the meaning of the Charitable Institutions Act, a placement co-ordinator described in subsection 9.6 (2) of that Act, a home or joint home within the meaning of the Homes for the Aged and Rest Homes Act, a placement co-ordinator described in subsection 18 (2) of that Act, a nursing home within the meaning of the Nursing Homes Act, a placement co-ordinator described in subsection 20.1 (2) of that Act or a care home within the meaning of the Residential Tenancies Act, 2006.

    3. A pharmacy within the meaning of Part VI of the Drug and Pharmacies Regulation Act.

    4. A laboratory or a specimen collection centre as defined in section 5 of the Laboratory and Specimen Collection Centre Licensing Act.

    5. An ambulance service within the meaning of the Ambulance Act.

    6. A home for special care within the meaning of the Homes for Special Care Act.

    7. A centre, program or service for community health or mental health whose primary purpose is the provision of health care.

  5. An evaluator within the meaning of the Health Care Consent Act, 1996 or an assessor within the meaning of the Substitute Decisions Act, 1992.

  6. A medical officer of health or a board of health within the meaning of the Health Protection and Promotion Act.

  7. The Minister, together with the Ministry of the Minister if the context so requires. Any other person prescribed as a health information custodian if the person has custody or control of personal health information as a result of or in connection with performing prescribed powers, duties or work or any prescribed class of such persons, pursuant to PHIPA.

Personal Health Information: means identifying information about a resident in oral or recorded form, if the information:

  1. relates to the physical or mental health of the individual, including information that consists of the health history of the individual's family,

  2. relates to the providing of health care to the individual, including the identification of a person as a provider of health care to the individual,

  3. is a plan of service within the meaning of the Long-Term Care Act, 1994 for the individual,

  4. relates to payments or eligibility for health care in respect of the individual,

  5. relates to the donation by the individual of any body part or bodily substance of the individual or is derived from the testing or examination of any such body part or bodily substance,

  6. is the individual's health number, or

  7. identifies a resident's substitute decision-maker, as defined by PHIPA.

Personal Information: means information about an identifiable individual, but does not include the name, title or business address or telephone number of an employee of an organization, as defined by the Personal Information Protection and Electronic Documents Act, 2000, c. 5 (hereinafter referred to as “PIPEDA”).

Privacy: means the safeguarding of personal, personal health, and confidential information from access or disclosure of such information without authorization as such authorization is set out in this Privacy Policy and in accordance with applicable federal and provincial legislation.

SENIORS LIVING DIVISION

Each site is considered a health information custodian and the staff are considered health information agents under PHIPA. Accountability for compliance to the privacy policy rests with the facility Privacy Officer, who is the Administrator / General Manager of the facility. All share responsibility for adhering to the company's privacy policies and procedures.

COLLECTION AND USE OF PERSONAL INFORMATION

The purposes for collection of confidential, personal, and personal health information include, but may not be limited to:

  • Making decisions about the types of services required by residents;

  • Providing appropriate direct resident care;

  • Communicating with other service providers and agents;

  • Monitoring the provision of services and evaluating the resident's response to services provided;

  • Administering quality control and risk management programs;

  • Providing payment for health care, services or products;

  • Providing employee payroll, benefit and pension administration programs and other services; and

  • Meeting legal and regulatory requirements.

Persons collecting confidential, personal, or personal health information will explain to the resident who is the subject of the information the purpose(s) for which the information is being collected, subject to applicable federal and provincial laws. Depending on the information required, the purpose may be stated orally or in writing.

The confidential, personal, or personal health information collected shall be limited to that which is necessary for the purposes identified by the facility, or as otherwise permitted by law.

CONSENT

Both PHIPA and PIPEDA require a resident's knowledgeable consent as defined in this Policy to collect, use or disclose the information.

Consent with respect to the collection, use or disclosure of confidential, personal, or personal health information about an individual or the facility may be express or implied, except in the following circumstances:

Consent to the disclosure of personal health information about a resident must be express, and not implied, if,

  1. the facility makes the disclosure to a person that is not a health information custodian; or

  2. the facility makes the disclosure to another health information custodian and the disclosure is not for the purpose of providing health care or assisting in providing health care.

Who may consent

  1. If the individual is capable of consenting to the collection, use, or disclosure of the information,

    1. the individual, or

    2. any person who is capable of consenting, whom the individual has authorized in writing to act on his or her behalf and who, if a natural person, is at least 16 years of age.

  2. If the individual is incapable of consenting to the collection, use or disclosure of the information, a person who is authorized under this policy.

  3. If the individual is deceased, the deceased's estate trustee or the person who has assumed responsibility for the administration of the deceased's estate, if the estate does not have an estate trustee.

  4. A person whom an Act of Ontario or Canada authorizes or requires acting on behalf of the individual.

Elements of consent: if this policy or applicable legislation requires the consent of a resident for the collection, use or disclosure of personal, or personal health information by the facility, or on behalf of another HIC, the consent,

  • must be a consent of the resident;

  • must be knowledgeable;

  • must relate to the information; and

  • must not be obtained through deception or coercion.

Knowledgeable consent: consent to the collection, use or disclosure of personal health information about a resident is knowledgeable if it is reasonable in the circumstances to believe that the individual knows:

  • the purposes of the collection, use or disclosure, as the case may be; and

  • that the individual may give or withhold consent.

Implied consent: The facility or its Agent that receives personal, or personal health information about a resident from the resident, the resident's substitute decision-maker or another HIC for the purpose of providing health care or assisting in the provision of health care to the resident, is entitled to assume that it has the resident's implied consent to collect, use or disclose the information for the purposes of providing health care or assisting in providing health care to the resident, unless the facility is aware that the resident has expressly withheld or withdrawn the consent.

Capacity to consent

A resident is capable of consenting to the collection, use or disclosure of personal health information if the individual is able,

  • to understand the information that is relevant to deciding whether to consent to the collection, use or disclosure, as the case may be; and

  • to appreciate the reasonably foreseeable consequences of giving, not giving, withholding or withdrawing the consent.

Different information

A resident may be capable of consenting to the collection, use or disclosure of some parts of personal health information, but incapable of consenting with respect to other parts, pursuant to PHIPA, s. 21(2).

Different times

A resident may be capable of consenting to the collection, use or disclosure of personal health information at one time, but incapable of consenting at another time, pursuant to PHIPA, s. 21(3).

Presumption of capacity

A resident is presumed to be capable of consenting to the collection, use or disclosure of personal and personal health information, and as a HIC, the facility staff or agents may presume a resident has such unless the staff person or agent responsible for such collection, use or disclosure on behalf of the facility has reasonable grounds to believe that the individual is incapable of granting such consent, pursuant to this policy and PHIPA, s. 21 (4) and (5).

Determination of incapacity

A health information custodian that determines the incapacity of a resident to consent to the collection, use or disclosure of personal health information under this Act shall do so in accordance with the requirements and restrictions, if any, that are prescribed in PHIPA.

Factors to consider for consent

A person who consents under this policy and applicable legislation on behalf of or in the place of a resident to collection, use or disclosure of personal health information by the facility, who withholds or withdraws such consent or who provides an express instruction shall take into consideration;

    the wishes, values and beliefs that,

    1. if the individual is capable, the person knows the individual holds and believes the individual would want reflected in decisions made concerning the individual's personal health information, or

    2. if the individual is incapable or deceased, the person knows the individual held when capable or alive and believes the individual would have wanted reflected in decisions made concerning the individual's personal health information;

    whether the benefits that the person expects from the collection, use or disclosure of the information outweigh the risk of negative consequences occurring as a result of the collection, use or disclosure;

    1. whether the purpose for which the collection, use or disclosure is sought can be accomplished without the collection, use or disclosure; and

    2. whether the collection, use or disclosure is necessary to satisfy any legal obligation.

Information about determination

If it is reasonable in the circumstances, the facility shall provide, to the resident determined incapable of consenting to the collection, use or disclosure of his or her personal health information, information about the consequences of the determination of incapacity, including the information, if any, that is prescribed pursuant to PHIPA, s. 22 (2).

Review of determination

A resident whom the facility determines is incapable of consenting to the collection, use or disclosure of his or her personal health information may apply to the Organization Chief Privacy Officer for a review of the determination unless there is a person who is entitled to act as the substitute decision-maker of the individual.

Incapable individual: persons who may consent

If a resident is determined to be incapable of consenting to the collection, use or disclosure of personal health information by the facility, a person described in one of the following paragraphs may, on the resident's behalf and in the place of the individual, give, withhold or withdraw the consent:

  1. The individual's guardian of the person or guardian of property, if the consent relates to the guardian's authority to make a decision on behalf of the individual.

  2. The individual's attorney for personal care or attorney for property, if the consent relates to the attorney's authority to make a decision on behalf of the individual.

  3. The individual's representative appointed by the Board under section 27, if the representative has authority to give the consent.

  4. The individual's spouse or partner.

  5. A child of the resident or other person who is lawfully entitled to give or refuse consent in the place of the resident.

  6. A brother or sister of the resident.

  7. Any other relative of the resident.

Requirements

A person may consent on behalf of the resident determined to be incapable of granting consent to the collection, use or disclosure of personal and personal health information only if the person,

  1. is capable of consenting to the collection, use or disclosure of personal or personal health information by the facility;

  2. in the case of an individual, is at least 16 years old or is the parent of the resident to whom the personal, or personal health information relates;

  3. is not prohibited by court order or separation agreement from having access to the resident to whom the personal, or personal health information relates or from giving or refusing consent on the resident's behalf;

  4. is available; and

  5. is willing to assume the responsibility of making a decision on whether or not to consent.

Authority of substitute decision-maker

Where this policy and applicable legislation permits or requires a resident to make a request, give an instruction or take a step and a substitute decision-maker is authorized to consent on behalf of the resident to the collection, use or disclosure of personal, or personal health information about the resident, the substitute decision-maker may make the request, give the instruction or take the step on behalf of the individual.  And such request made, instruction given or step taken by the substitute decision-maker shall be read as references to the substitute decision-maker, and not to the individual.

Potential residents of the facility authorize the collection and sharing of personal health information upon admission process in writing.

Residents authorize in writing the sharing of contact information by expressed consent in the admission process.

Residents authorize the use of personal banking information in the admission process by implying consent when completing the automatic bank payment option on admission.

Withdrawal of consent:

If a resident consents to the facility collecting, using or disclosing personal, or personal health information about the resident, the resident, or the resident's substitute decision maker if the resident is determined to be incapable, may withdraw the consent, whether the consent is express or implied, by providing notice to the facility.

The withdrawal of the consent shall not have retroactive effect, and withdrawal of such consent will only be permitted where the withdrawal will not compromise the provision of care to the resident by the facility or other HIC, or such information is required by the facility to comply with applicable legislation.

OPENNESS AND ACCURACY

The facility endeavours to ensure that any personal and personal health information provided by its residents and in its possession is as accurate, current and complete as necessary for the purposes for which the data is collected and used.

A resident or a resident's substitute decision maker may, upon written request of the facility Privacy Officer, see that file or files containing the resident's personal information, subject to applicable law. If personal, or personal health information is found contained in the file or files, the facility Privacy Officer will ensure the residents record is amended accordingly upon receipt of documentary proof that the subject information is incorrect or missing, and similar documentation demonstrating the correct or missing information.

DISCLOSURE

Under PHIPA, health care facilities that provide health care may provide the following information to friends or family that make inquires:

  • confirmation that an individual is a resident

  • the individual's general health status; and

  • the location of the individual in the residence.

Personal and health information will be used and disclosed for the purposes identified. The facility may disclose personal and personal health information to another HIC if the disclosure is reasonably necessary for the provision of health care and it is not reasonably possible to obtain consent in a timely manner, or where the disclosure is necessary for eliminating or reducing a significant risk of serious harm.

RECORD RETENTION AND SECURITY SAFEGUARDS

Record Retention:

Resident Records are retained for the duration of their stay at the facility. Upon transfer and relocation to another HIC, the resident's record will be transferred to the HIC by courier so as to safeguard the confidentiality of the resident's personal and personal health information.

If a resident dies, the facility will retain the file for seven (7) years after the date of the resident's death, or for the period required to comply with applicable legislation.

If the resident dies while temporarily outside the facility (e.g. hospital, home visit), the facility will retain the file for twenty (20) years after the date of the resident's death, or for the period required to comply with applicable legislation.

Organizational Security Safeguards:

In accordance with this policy and the Seniors' Living Code of Conduct, all staff and volunteers are required to comply with this policy and are notified of their duties and obligations with respect to compliance with this policy by being provided with and signing their agreement to so comply in the Staff Handbook.

Staff and volunteer compliance with this policy and the Seniors' Living Code of Conduct extends to facility Confidential Information as defined in this policy.

Contractors or third party service providers who may receive personal, or personal health information in the course of providing services to the facility will protect that information in a manner consistent with the principles outlined in this policy statement, and will execute third party confidentiality agreements as provided by the Corporate Privacy Officer prior to providing services to the facility.

Physical Security Safeguards

Resident records in paper format are stored in the Wellness Centre and in the Business Office in locked cabinets, access to which records are restricted only to those staff with authorization to access such records. The Circle of Care for each resident allows access to information if necessary for ongoing treatment to those active in the care of the individual.

Records of personal and personal health information are retained, transferred and disposed of in a secure manner.

Technological Security Safeguards

Electronic information is secured by personal password protection on the computer network system, firewalled by the latest technology, and limited in access based on a need to know basis. Monitoring of the technology system is completed corporately.

QUESTIONS OR COMPLAINTS

A resident or a resident's family, spouse, or substitute decision maker where the resident consents to the complaint being made on his or her behalf, or is determined to be incapable, may direct questions, concerns or complaints respecting the handling of their personal, or personal health information to the facility Privacy Officer. All questions and complaints will be investigated promptly and a written report provided to the resident or resident's representative.

If the resident or the resident's representative is not satisfied with the results of the report, he or she may make their concern or complaint known to the Corporate Privacy Officer at: sbrady@sifton.com The Corporate Privacy Officer will investigate the complaint or issue promptly and report in writing to the resident or resident's representative.

If the resident or the resident's representative is not satisfied with the results of the report from the Corporate Privacy Officer, a complaint may be directed to the Privacy Commissioner for Ontario, for issues respecting the handling of personal health information, as defined under PHIPA, or the Office of the Privacy Commissioner for issues respecting the handling of personal information as defined under PIPEDA. Contact information for the offices of the provincial and federal privacy commissioners is as follows:

Complaints under PIPEDA,
to be made in writing:
Office of the Privacy Commissioner
112 Kent Street, Place de Ville
Tower B, 3rd Floor
Ottawa, Ontario K1A 1H3

Complaints under PHIPA,
to be made in writing:
Information and Privacy Commissioner/Ontario
2 Bloor Street East, Suite 1400
Toronto, Ontario M4W 1A8

POLICY NOTICE

A summary of this policy, in the form of a Privacy Notice, is to be posted in a general area(s) where it is available to residents and the residents' families, spouses, substitute decision makers for review at all times and includes who to contact if there is a concern or question relating to the policy or any suspected violation.

The organization reserves the right to amend this policy as required to comply with privacy and other provincial and federal legislation. Any amendments to the said policy will have no retroactive effect, and be in force as of the date that it is posted on the Sifton Group of Companies Web site.
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Sifton Properties Ltd.
P.O. Box 5099
London, ON  N6A 4M8
P: (519) 434-1000
F: (519) 434-1009
E: info@sifton.com