DISCLOSURE OF FACILITY DIRECTORY INFORMATION TO CLERGY

SCOPE: This policy applies to The Health System and its affiliated facilities, including but not limited to hospitals, long-term care, assisted and independent living and residential facilities.

POLICY:

Part of the health care organizations' mission is to continue the healing ministry of Jesus by providing compassionate, quality health care services. The health care organization employs spiritual care staff to meet individuals and families' spiritual needs. Local clergy are encouraged to provide for their congregants' spiritual needs when they are at a Health System facility.

THIS POLICY ONLY APPLIES TO EXTERNAL CLERGY AND DOES NOT APPLY TO THE HEALTH SYSTEMS SPIRITUAL CARE STAFF.

1. Qualified and authorized members of the clergy as defined in this policy may have access to information in the facility directory provided they agree to and sign the Clergy Confidentiality Agreement (see Appendix A).
    
2. Health facilities will disclose an individual's (i.e. patient, resident or client) facility directory information to clergy unless the individual or his/her personal representative objects to the disclosure or is unable to respond.

DEFINITIONS:

Clergy (or Visiting Clergy) – qualified and authorized member of a faith community, such as a minister, priest, rabbi, accredited Christian Science Practitioner, Eucharistic minister, lay volunteer or similar functionary, who is a duly designated representative of a local parish, congregation or religious organization. Deacons within the Roman Catholic faith are also members of the clergy.

Facility Directory – individually identifiable information maintained by the Health facility in a directory, available to visitors upon request, which includes:

• individual's name,
• individual's location within the facility,
• individual's general health care condition (e.g., stable, critical)
• individual's religious affiliation (available only to clergy)

Spiritual Care Staff – all persons officially listed with the Health System's Pastoral Care Department as full time or auxiliary staff. These persons, who provide spiritual/pastoral care to patients/residents, family members and staff, may access protected health information needed to fulfill their professional responsibilities, similar to other members of the health care team.

PROCEDURES:

The Health facilities maintain a facility directory that lists individuals' names, room numbers, general health status (e.g., stable) and known religious affiliations.

These procedures apply to individuals who approve the Health System's use and disclosure of their PHI in its facility directory.

A.   Initial Facility Visit: Clergy Request for Access to Facility Directory Information

When a member of the clergy visits, The Health System Facilities will provide him/her with information from the facility directory for individuals from his/her religious affiliation. Information desk or chaplaincy services personnel will do the following during a clergy member's initial facility visit:

1. Verify that the clergy member is authorized to obtain facility directory information; Clergy member must present verification of clergy status. See Clergy Verification Guidance Addendum.
    
2. Review Clergy Confidentiality Agreement with the clergy member;
    
3. Obtain the clergy member's signature on the Clergy Confidentiality Agreement (see Appendix A) and file the agreement with chaplaincy services.
    
4. Chaplaincy services will add clergy member's name to approved clergy listing.
    
5. Verify that the facility directory information provided to the clergy member does not include information for individuals who have not given permission for their information to be included in the facility directory; and
    
6. Provide the clergy member with facility directory information.

B.   Facility Visits: Clergy Request for Access to Facility Directory Information

When a member of the clergy visits, The Health System Facilities will provide him/her with information from the facility directory for individuals from his/her religious affiliation when requested. Information desk/chaplaincy services personnel will do the following during a clergy member's visits:

1. Check for clergy member's name in authorized clergy member listing. If the clergy member is not listed, do not proceed and inform him/her that inclusion in our clergy listing is required before information may be released. See procedure A above.
    
2. Verify that the facility directory information provided to the clergy member does not include information about individuals who have not given permission for their information to be included in the facility directory; and
    
3. Provide the clergy member with facility directory information.

C.   Disclosures to Clergy During Emergency Treatment Situations

If an individual or his/her personal representative is unable to respond or it is unknown whether the individual would object to the disclosure of his/her facility directory information to clergy, professional medical or nursing staff will do the following:

1. Professional staff should use their judgment to determine whether it is in the individual's best interest to disclose his/her facility directory information; if disclosure is considered to be in the individual's best interest, follow steps 1 – 3 in section B above; or
    
   If disclosure is not considered to be in the individual's best interest, direct clergy to chaplaincy services or the Privacy Official for direction; and
    
2. When the individual has stabilized or otherwise becomes capable of decision making, ask if the individual would like to have his/her facility directory information disclosed to clergy;
    
3. If the individual agrees to the disclosure, follow steps 1 – 3 in section B above; or
    
4. If the individual objects to the disclosure, document the restriction and make no further disclosures to clergy.

D.   Re-Verification of Clergy

The Health System will verify the status of clergy and obtain clergy's signatures on the Clergy Confidentiality Agreement every three years.

1. Chaplaincy services will send lists of clergy members on file to religious organization directors, staff members or other qualified individuals at their local congregations every three years;
    
2. Each religious organization director, staff member or other qualified individual will confirm with the health system the clergy still serving the community;
    
3. Clergy still serving the community will sign the Clergy Confidentiality Agreement (see Appendix A);
    
4. Chaplaincy services will file the agreement

E.   Clergy Request for Access to Facility Directory Information by Telephone

The Health System Facilities will provide facility directory information by phone to members of the clergy provided that the church or other religious organization is listed in our church directory and only if the caller can validate that listing by giving us their church code listing from the directory.

GUIDANCE ADDENDUM

Examples of Appropriate Clergy Verification

Examples of verification mediums include:

1. Clergy identification badge or card
   1. Picture identification badge
   2. Clergy visitor badge (without picture)
       
2. Picture identification (e.g., driver's license)
    
3. Ordination card
    
4. Call to religious organization director, office staff member or other qualified individual for verification
    
5. Letter of qualification
    
6. The Health System's church directory listing code number

The Health System will regularly (e.g., every three years) verify the status of clergy by sending a list to local congregations and asking religious organization directors, staff members or other qualified individuals to verify that the identified clergy members are still providing spiritual services on behalf of their religious organizations.

APPENDIX A

Community Clergy Confidentiality Agreement

We deeply appreciate Community Clergy's support of and ministry to the spiritual needs of the congregation members while a patient at our Health System facility.

As part of our ongoing responsibility to protect the patient's privacy and confidentiality, and to fulfill the requirements of the Federal Health Insurance Portability and Accountability Act's Privacy Rule (HIPAA), we ask that you review the Health System's attached policy and procedure for releasing confidential information to community clergy.

The HIPAA Privacy Rule establishes federal protections for the patient's health information. The federal rule permits a hospital to share a patient's health information with community clergy; however, it is limited to the information that is minimally necessary to carry out the ministry needs of the patient. Additionally, the legal and moral fidelity owed to the patient is based upon the respect for his or her autonomy.

The Health System is complying at every level with HIPAA's Privacy Rule. Each staff person and every volunteer is signing a document similar to this. All Health System facilities will ask its clergy who use the patient census information to indicate this understanding and to acknowledge his or her agreement to comply with the policy.

You have received a copy of our policy and procedure. Please read the policy and then sign this confidentiality agreement. Return one copy in the enclosed self-addressed stamped envelope. The second copy is for your records.

As a person who meets the definition of "Clergy" in the attached policy, I accept the following guidelines for maintaining the confidentiality of the patient's health information that I receive in performing my duties as clergy. I agree to the following:

1. Information that I receive from the Health System regarding a congregation member-patient is confidential and may only be used for the patient's benefit, and I will only receive and use the information as minimally necessary to provide spiritual and religious support to the patient.
    
2. I will maintain the confidentiality of personal conversations between the patient and myself and will not share the information unless I obtain the patient's permission.
    
3. I have read the attached Policy and have had an opportunity to ask questions. I promise to abide by its terms, understanding that any breach of the confidentiality will result in forfeiture of my right to access information about patients at the Health System.

Signature:                                             Date:                         Denomination:                              

Printed Name:                                             Church Affiliation: