Use of Notice of Privacy Practices

Effective Date:    February 16, 2026

References:         45 CFR 164.520

PURPOSE

To ensure that a Notice of Privacy Practices is provided to, and acknowledged by, each resident/client or his/her responsible individual upon admission to Dunwoody Village

POLICY

Dunwoody Village will provide a comprehensive Notice of Privacy Practice to all residents/ responsible individuals for those residents unable to make healthcare decisions.

The notice shall include all elements and statements that are required by law. The notice shall inform the residents of:

1. A statement indicating how a resident’s medical and substance abuse treatment information may be used and disclosed and how the resident can obtain access to such information;
2. A description, including at least one example, of the types of uses and disclosures that the organization is permitted to make for purposes of treatment, payment and healthcare operations, with sufficient detail to place an individual on notice of the uses and disclosures permitted or required;
3. A description of each of the other purposes for which the organization is permitted or required to use or disclose PHI without the resident’s consent or authorization, with sufficient detail to place an individual on notice of the uses and disclosures permitted or required;
4. A statement that other uses or disclosures will be made only with the resident’s written authorization, and that the authorization may be revoked in accordance with the policy on authorization;
5. A statement of the resident’s rights with respect to his/her PHI, and a brief description of how the resident may exercise those rights, including:
   1. The organization will comply with a requested restriction, if the restriction relates to the provision of PHI to a health plan for a service paid for by the resident or person on behalf of the resident;
   2. The right to receive confidential communications of PHI;
   3. The right to inspect and copy PHI;
   4. The right to amend PHI;
   5. The right to receive an accounting of disclosures of PHI; and
   6. The right to receive a paper copy of the privacy notice
   7. The resident has the right to opt out if the PHI will be used for fundraising.
   8. The resident has the right to be notified of a breach of their PHI.
6. A statement of the organization’s duties with respect to PHI, including statements:
   1. That the organization is required by law to maintain the privacy of PHI and to provide residents with notice of its legal duties and privacy policies;
   2. That the organization is required to abide by the terms of its current effective privacy notice; and
   3. That the organization reserves the right to change the terms of the notice and make the new notice provisions effective for all PHI maintained, along with a description of how the facility will provide residents with the revised notice.
7. A statement that residents may complain to the organization and to the Secretary of the US Department of Health and Human Services about privacy rights violations, including a brief statement about how a complaint may be filed and an assurance that the resident will not be retaliated against for filing a complaint; (Refer to policy entitled Privacy Complaints and Investigations.)
8. The name, or title, telephone number and email address of the organization’s Privacy Officer to contact for further information;
9. The name, telephone number, address and email address of the person designated by Dunwoody Village to receive complaints regarding our organization’s privacy practices; and
10. The effective date of the notice, which may not be earlier than the date printed or published.

PROCEDURE

1. The Notice and Acknowledgement forms will be included in the standard admission packet.
2. The organization will provide the Notice to the resident/client at time of admission.
3. The organization will make a good faith effort to obtain the resident’s signature on the Acknowledgement at the time the Notice is provided. The Notice and signed Acknowledgement will be kept in the resident’s file.
4. If the resident refuses or is otherwise unable to sign the Acknowledgement, the organization will document, on the Acknowledgement form, what actions were taken to obtain the resident signature on the Acknowledgement and the reason(s) why a signed Acknowledgement was not obtained. This document will then be maintained in the resident file.
5. A copy of the written Notice will be provided to residents and to other persons upon request.
6. The organization will post a copy of the Notice in a clear and prominent location for each level of care or service that may include the entrance lobby, entrance to PCH/AL Clinic etc.
7. A current version of the Notice will be maintained on the organization’s website.
8. Whenever the Notice is revised, the Dunwoody Village Compliance Official will assure that:
   1. The revised Notice is made available upon request on or after the effective date of the revision; and
   2. The revised Notice is posted in clear and prominent locations throughout the organization.
9. A copy of each Notice issued by the organization will be maintained for at least six years from the date it was last in effect.
10. Any member of the workforce who has knowledge of the violation or potential violation of this Policy must make a report directly to the Privacy Officer.