Who We Are

Holy Family Institute and Its Affiliates
Notice of Privacy Practices

THIS NOTICE DESCRIBES THE INFORMATION COLLECTION, USE, AND SHARING PRACTICES OF HOLY FAMILY INSTITUTE. IT EXPLAINS HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

WHO WILL FOLLOW THIS NOTICE

This notice describes the information privacy practices followed by our employees and volunteers.

YOUR HEALTH INFORMATION

This notice applies to the information and records we have about your personal identifiable information, mental and/or physical health and the services you receive at Holy Family Institute. Holy Family Institute collects information in multiple ways including from referents, third parties, and information you voluntarily provide through direct contact and electronic devices.

We are required by law to give you this notice.  It will tell you about the ways in which we may use and disclose information about you and describes your right, as well as our obligations regarding the use and disclosure of that information.

In all cases when we disclose information about you, we will only provide the minimum necessary information to meet the requirement in order to ensure the highest level of privacy.

The confidentiality of alcohol and drug abuse patient records is specifically protected by Federal law 42 CFR Part II and state laws 28 Pa Code 709.28 and 4 Pa Code 255.5.; we are required to comply with these additional restrictions.  This includes a prohibition, with very few exceptions, on informing anyone outside of the program that you are attending or have attended the program or disclosing any information that identifies you as someone who has abused substances, or someone who is dependent upon drugs or alcohol.  The exceptions are as follows:

1. You consent in writing
2. The disclosure is allowed by a court order
3. The disclosure is made to medical personnel in a medical emergency
4. The disclosure is made to designated and qualified staff for research
5. Audit or program evaluation
6. The disclosure is regarding information about a crime committed by a patient either at this program or against any person who works for the program or about any threat to commit such a crime
7. Disclosure of information regarding suspected child abuse or neglect to appropriate state or local authorities

CHANGES TO THIS NOTICE OF PRIVACY PRACTICES

We reserve the right to change our privacy practices and this Notice. If we make a material change to our practices, we will:

1. Notify you about the change.
2. Post the new Notice on our website.
3. Provide you with a copy of this Notice elec­tronically or through the mail.
4. We may apply revised practices to existing and new PHI.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment

We may use information about you to provide treatment or services.  We may disclose information to therapists, doctors, nurses, or other personal who are involved in taking care of you at Holy Family Institute.  For example, a treatment team comprised of various professionals may meet to help determine the most appropriate care for you and are permitted to disclose health information to determine the best course of treatment.

For Payment

We may use and disclose information about you so that the treatment and services you receive at Holy Family Institute may be billed to and payment may be collected from  you, an insurance company or third party.  For example, we may need to give your health plan information about a service received here so your health plan will pay us or reimburse you for the service.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will cover the treatment.

For Health Care Operations

We may use and disclose health information about you in order to run the organization and make sure that you and our other clients receive quality care.  For example, we may use treatment information to evaluate and improve the quality of services that we provide to clients.

Appointment Reminders and General Contact

We may contact you as a reminder via phone, email, or text SMS messaging to provide information or that you have an appointment for treatment. Consent for text messaging will be included in your program consent. You have a right to opt out of SMS text messages. Messages will include an option to stop text messages.

Please notify us in writing if you do not wish to be contacted for appointment reminders.

SPECIAL SITUATIONS

We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety

We may use and disclose treatment information about you when necessary to prevent a serious threat to the health and safety of you, the public or another person.

Required by Law

We will disclose treatment information about you when required to do so by federal, state or local law.

Research

We may use and disclose treatment information about you for research projects that are subject to a special approval process.  We will ask you for your permission if the researcher will have access to your address or other information that reveals your identity.

Military, Veterans, National Security and Intelligence

If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release treatment information about you.  We may also release information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation

We may release treatment information about you for workers’ compensation or similar programs.  These programs provide benefits for work related injuries or illnesses.

Public Health Risks

We may disclose treatment or service information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

Health Oversight Activities

We may disclose treatment or service information to a health oversight agency for audits, investigations, inspections, risk management or licensing requirement purposes.  These disclosures may be necessary for certain state and federal agencies to monitor government programs and compliance with civil rights laws.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, we may disclose treatment information about you in response to a court or administrative order.  Subject to all applicable legal requirements, we may also disclose treatment information about you in response to a subpoena.

Law Enforcement

We may release treatment or service information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Coroners, Medical Examiners and Funeral Directors

We may release treatment or service information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.

Information Not Personally Identifiable

We may use or disclose treatment or service information about you in a way that does not reveal your identity.

Family and Friends

We may disclose treatment or service information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection.  We may also disclose treatment information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object.  For example, we may assume you agree to our disclosure of your personal treatment information to your spouse when you bring your spouse with you into a treatment session where treatment is discussed.

In situations where you are not capable of giving consent because you are not present or due to your incapacity or medical emergency, we may, using our professional judgement, determine that a disclosure to your family member or friend is in your best interest.  In that situation, we will disclose only information relevant to the person’s involvement in your care.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

We will not use or disclose treatment or service information for any purposes other than those identified in the previous sections without your specific, written, authorization.  The following uses and disclosures, with limited exceptions, require authorization:

• Direct disclosure of a child’s PHI to the child’s school to permit the child’s participation in sports activities
• Sale of a client list
• Disclosure of PHI to an employer
• Disclosure of PHI to a life insurer for underwriting/eligibility for insurance
• Disclosure to an attorney
• Fundraising
• Marketing

If you give us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time.  If you revoke your authorization, we will no longer use or disclose information about you for the reasons covered by your written authorization, but we cannot take back any uses or disclosures already made with your permission.  In order to revoke an authorization, submit the Revocation of Authorization form and submit to the Privacy Officer.

If this health information concerns substance abuse and/or HIV status, we may be very limited in what we provide and may be required to first obtain specific authorization from you.

Privacy Officer Information

Vince Tarquinio LSW
8235 Ohio River Boulevard
Pittsburgh, PA 15202
412-766-9020 x1315
tarquinio.vince@hfi-pgh.org

This website is the property of Holy Family Institute (HFI). HFI does not collect personal information from visitors/users of the website without the consent of the user. Users that voluntarily provide personal information can expect their privacy to be respected, and that the information will only be used to fulfill user requests, such as service requests, donations, and requests for information. No personally identifiable information is shared with third parties.  "Personally identifiable information" is information that would allow someone to identify or contact you or your computing device, which may include, for example, your name, address, telephone number, email address, payment or identity verification information, gender, age, and date of birth. 

HFI collects non-personally identifiable information for the purpose of managing this website. The information collected may include, but is not limited to: your IP address, browser type and language, referring and exit pages and URLs, search engine used, other browser history, platform type, number of clicks, landing pages, cookie information, the pages you requested and viewed, the amount of time spent on particular pages, and the date and time of your visit. However, none of this statistical information is used to identify site visitors.

HFI makes commercially reasonable efforts to protect user information from loss, misuse, or unauthorized access, disclosure, alteration or destruction.  All transactions occur on secure pages using SSL technology, which is the generally accepted standard for secure web transactions.  We use a third party payment processor for all transactions, and we do not store any credit card information.  However, we cannot guarantee that your personally identifiable information will never be disclosed in ways not otherwise described in this Privacy Policy.  For example, we may be required to disclose personal information to the government or third parties under certain circumstances, third parties may unlawfully intercept or access transmissions or private communications, or users may abuse or misuse personal information that they collect from the Sites.  No transmission of data over the internet can be 100% secure. We therefore can not provide any expressed or implied guarantees of security or confidentiality of personally identifiable information.

Holy Family Institute and Its Affiliates

Quality Improvement Stakeholder Overview

Purpose of Quality Improvement: Holy Family Institute (HFI) and its affiliates are committed to fostering a culture of quality and accountability. By monitoring performance indicators and using data to continuously improve our services and drive decision-making, we can ensure that HFI and its affiliates continue to provide high quality services.

Quality Improvement Principles: HFI's and its affiliate's approaches to quality improvement are based on the following principles:

• Customer/Consumer Focus - We focus on both our internal and external customers and consumers, and on meeting or exceeding needs and expectations.
• Employee Empowerment - In order to be effective, people at all levels of the organization are involved in improving quality.
• Leadership Involvement - Strong leadership, direction, and support of quality improvement activities by the governing body and Administrative Team are key to our successful implementation of quality improvement.
• Data-Informed Practices - We create feedback loops, using data to inform practice and measure results. Fact-based decisions are likely to be correct decisions. Some methods used to collect data include, but are not limited to:
• Proactive Over Reactive - We seek to design good processes to achieve excellent outcomes rather than fix processes.
• Continuous Improvement - Processes must be continuously reviewed and improved.

Quality Improvement Priorities: Quality improvement priorities will focus on those processes that are:

• High risk - processes or program/departmental areas that place consumers and/or staff at risk.
• High volume - processes that occur frequently or affect large numbers of consumers and/or staff.
• Requirements from regulatory agencies or accrediting bodies, ie. COA, DPW, PDE, etc..
• Sentinel events.
• Impacting upon HFI and its affiliate's ethics or values.
• Exhibiting levels of performance that vary significantly from expectations.
• Exhibiting levels of performance that vary undesirably from comparison data.
• Directly related to strategic goals.

Quality Improvement Structure:

Risk, Compliance, and Quality Management (RCQM) Board Subcommittee

Structure and Responsibilities

The purpose of the RCQM Board Subcommittee is to review high-level organizational risk, compliance, and quality information and provide oversight to the quality, risk, and compliance activities of the organization. This Subcommittee reviews the following information:

• External Licensing Reviews
• Client Record Reviews
• Incidents/Accidents (staff and client)
• Client Satisfaction
• Grievances and Allegations
• Client Outcomes
• COA Self Reports

Quality Committee

Structure and Responsibilities

The purpose of the Quality Committee is to provide oversight of the quality and risk activities of the organization. The Quality Committee is responsible for reviewing data to identify opportunities for improvement and areas of strength. The Quality Committee assesses whether changes in procedures achieved the anticipated outcome and whether established measures have been met.

Safety Committee

Structure and Responsibilities

The purposes of the Safety Committee include:

• Establish and monitor performance measures and develop, communicate, and recommend action plans related to:
  • Facility and motor vehicle safety and security
  • Emergency management
  • Consumer and staff injuries
  • Worker's compensation
  • Consumer critical incident
  • Other items as deemed appropriate
• Proactively prevent potential occurrences of future injury or incidents

Restraint Review Committee

Structure and Responsibilities

The purposes of the Restraint Review Committee include:

• Review each individual restraint for: compliance with regulations, proper utilization of techniques, proper/thorough completion of paperwork
• Identify concerning issues with individual restraints, as well as trends or patterns that need to be corrected
• Utilize information gleaned to inform future CPI trainings

Stakeholders

Stakeholder involvement in Quality Improvement is solicited in many different ways at HFI and its affiliates:

• Staff Satisfaction Survey - Annual
• Consumer Satisfaction Surveys- Annual for all and at Discharge for In-Home, SHORES (Support Hours of Recovery to Ensure Sobriety), SNAP™ (Stop Now and Plan™), and Residential
• External Stakeholder Survey (caseworkers, referring entities, etc.) - Annual
• Staff Exit Survey - On-going
• Consumer Follow-Up Survey - 6 and 12 months for Residential
• Red Flag Meetings - Staff at any level in the organization can initiate a Red Flag Meeting to discuss issues that are problematic. These meetings lead to improvement activities that are monitored through appropriate program and/or department personnel.

Management/Operational Performance

In terms of management/operational performance, the organization collects, analyzes, and acts on the following indicators:

• Staff turnover
• Staff satisfaction (exit and annual)
• Financial stability
• Staff injuries
• Facility safety and security

Program Results/Service Delivery Quality

In terms of program results/service delivery quality, the organization collects, analyzes, and acts on the following indicators:

• Client satisfaction
• External stakeholder satisfaction
• Consumer critical incidents/accidents
• Restrictive procedures
• Medication incidents
• Chart audits
• Grievances
• Allegations

Client and Program Outcomes

In terms of client and program outcomes, the organization, collects, analyzes, and acts on the following indicators:

Residential

• Case status at discharge
• Goal success rating at discharge
• Restrictiveness of discharge placement
• Academic success
• Permanency and school/employment at 6 and 12-months post-discharge

Education

• Individualized Education Plan (IEP) goal progress
• Change in Grade Point Average (GPA)
• Pennsylvania System of School Assessment (PSSA) practice test results

Outpatient

• Case status at discharge
• Change in Global Assessment of Functioning (GAF) score
• Goal success rating at discharge

In-Home

• Number of children residing in a family setting at discharge
• Number of families with reduced risk scores at discharge
• Achievement of identified goals at discharge
• Number of families connected to community resources at discharge
• Independent youth will complete their plans (Armstrong In-Home Independent Living only)

Family Focused Solution Based (FFSB)

• Number of children residing in a family setting at discharge
• Number of families with reduced GAF scores at discharge
• Achievement of identified goals at discharge
• Number of families connected to community resources at discharge

Family Group Decision Making

• Number of children remaining within a family setting at discharge
• Number of families who established a goal plan at discharge
• Number of families who implemented their goal plans at discharge

SHORES

• Case status at discharge
• Goal success rating at discharge

SNAP™

• Change in Child Behavior Check List (CBCL)
• Change in Teacher's Report Forms (TRF)
• Change in Earl 20-B
• Change in Self-Report Antisocial Behavior (SRA) Score

Improvement Model

HFI and its affiliates have selected the Shewhart Plan-Do-Study-Act (PDSA) model as its method of improving organizational performance. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test or trying it (Do), observing and learning from the consequences (Study), and then acting on what is learned from those consequences (Act), a process that is iterative.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. mail:
   U.S. Department of Agriculture
   Office of the Assistant Secretary for Civil Rights
   1400 Independence Avenue, SW
   Washington, D.C. 20250-9410; or
2. fax:
   (833) 256-1665 or (202) 690-7442; or
3. email:
   Program.Intake@usda.gov

This institution is an equal opportunity provider.

HFI and Nazareth Prep School Wellness Policy 12.2023

For a copy of the triennial Wellness Policy Assessment, please contact adams.andrew@hfi-pgh.org.

DFN Civil Rights Complaint Procedure