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Nondiscrimination Notice

Sheepshead Nursing and Rehabilitation Center does not exclude, deny benefits to, or otherwise discriminate against persons who are residents or desiring to be admitted to the Facility on the
basis of race, color, ancestry, national origin, citizenship, religion, creed, sex, marital status, actual or perceived sexual orientation, gender identity or expression, HIV status, military blindness, age, pregnancy, disability, genetic information, sponsorship in admission, retention and care of residents or any other basis protected by applicable federal, state or local laws or regulations.

Appropriate auxiliary aids and services as well as language assistance services are available free of charge. If you need assistance with the above services, please contact the Compliance and
Ethics Officer, Director of Human Resources, by phone at 718-646-5700 ext. 123 or mail at 2840 Knapp Street, Brooklyn, NY 11235.

If you believe that Sheepshead Nursing and Rehabilitation Center has failed to provide these services or discriminated in another way you can file a grievance by contacting the Compliance and Ethics Officer, who is responsible for coordinating or facilitating the Facility’s nondiscrimination policy, by phone at 718-646-5700 ext. 123 or mail at 2840 Knapp Street, Brooklyn, NY 11235. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

SHEEPSHEAD NURSING AND REHABILITATION CENTER DOES NOT DISCRIMINATE AND DOES NOT PERMIT DISCRIMINATION, INCLUDING, BUT NOT LIMITED TO, BULLYING, ABUSE, HARASSMENT, OR DIFFERENTIAL TREATMENT ON THE BASIS OF ACTUAL OR PERCEIVED SEXUAL ORIENTATION, GENDER IDENTITY OR EXPRESSION, OR HIV STATUS, OR BASED ON ASSOCIATION WITH ANOTHER INDIVIDUAL ON ACCOUNT OF THAT INDIVIDUAL’S ACTUAL OR PERCEIVED SEXUAL ORIENTATION, GENDER IDENTITY OR EXPRESSION, OR HIV STATUS. YOU MAY FILE A COMPLAINT WITH THE OFFICE OF THE NEW YORK STATE LONG-TERM CARE OMBUDSMAN PROGRAM AT 855-582-6769 IF YOU BELIEVE THAT YOU HAVE EXPERIENCED THIS KIND OF DISCRIMINATION.

Language Assistance Services

EnglishATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 718-646-5700.

Español (Spanish)ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 718-646-5700.

繁體中文 (Chinese)注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 718-646-5700。

Русский (Russian)ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 718-646-5700.

Kreyòl Ayisyen (French Creole)ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 718-646-5700.

한국어 (Korean)참고: 한국어를 사용하는 경우 언어 지원 서비스를 무료로 이용할 수 있습니다. 718-646-5700으로 전화하십시오.

Italiano (Italian)ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica
gratuiti. Chiamare il numero 718-646-5700.

אידיש (Yiddish)אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט 718-646-5700.

বাঙ্গালি (Bengali)লক্ষ্য করুনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে। ফোন করুন 718-646-5700.

Polski (Polish)UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 718-646-5700.

العربية (Arabic)ملاحظة: إذا كنت تتحدث العربية ، فإن خدمات المساعدة اللغوية متاحة لك مجانًا. اتصل على 5700-646-718.

Français (French)ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 718-646-5700.

ردُو (Urdu)نوٹ: اگر آپ اردو بولتے ہیں، تو آپ کے لیے لینگویج سپورٹ سروسز مفت دستیاب ہیں۔ کال کریں۔718-646-5700

Tagalog (Tagalog – Filipino)PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 718-646-5700.

Ελληνικά (Greek)ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, οι υπηρεσίες γλωσσικής βοήθειας, δωρεάν, είναι διαθέσιμες σε εσάς. Καλέστε το 718-646-5700.

Shqip (Albanian)KUJDES: Nëse flisni shqip, ofrohen shërbime mbështetëse gjuhësore falas. Telefononi 718-646-5700.

한국어 (Korean)참고: 한국어를 사용하는 경우 언어 지원 서비스를 무료로 이용할 수 있습니다. 718-646-5700.

Tiếng Việt (Vietnamese)CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 718-646-5700.

עברית (Hebrew)הערה: אם אתה דובר עברית, שירותי סיוע בשפה זמינים ללא תשלום. 718-646-5700.

Deutsch (German)ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 718-646-5700.

فارسی (Farsi)ﺗوﺟﮫ :اﮔر ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺗﮕو ﻣﯽ ﮐﻧﯾد، ﺗﺳﮭﯾﻼت زﺑﺎﻧﯽ ﺑﺻورت راﯾﮕﺎن ﺑرای ﺷﻣﺎ 1 ﻓراھم ﻣﯽ ﺑﺎﺷد .ﺑﺎ . – ﺗﻣﺎس ﺑﮕﯾرﯾد 718-646-5700.

Հայերեն (Armenian)ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 718-646-5700.

Português (Portuguese)ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 718-646-5700.

Pandemic Emergency Plan

IntroductionSheepshead Nursing and Rehabilitation Center shall maintain a Pandemic Emergency Plan (PEP). A pandemic is an outbreak of an infectious disease over an extensive geographical area. During a pandemic the facility may need to implement restricted visitation, manage a shortage of staff and/or personal protective equipment and more difficult issues that may threaten the facility’s ability to remain operational.

PurposeThe PEP is designed to aid in the preparedness, response and recovery of pandemics in accordance with state and federal requirements.

Relationship to the Emergency Management PlanThe PEP is intended to serve as a section of the facility’s overall Emergency Management Plan.

Updates and RevisionsThe PEP will be reviewed and updated when deemed necessary and at least annually.

ActivationThe PEP shall be activated when required due to a Pandemic declared by either Federal or New York State authorities.

Updates and RevisionsThe PEP will be reviewed and updated when deemed necessary and at least annually.

PEP Location

• The PEP shall be kept as a part of the Emergency Management Plan.
• The PEP will be posted on the facility’s website and made available immediately upon request in accordance with NYS regulations.

Infection Prevention and Control Policies and Procedures

• The Infection Preventionist/Designee will obtain guidance from the NYSDOH and CMS on disease-specific response actions. The facility receives regulatory guidance via the HCS and from the facility’s Nursing Home Association.
• The facility will develop, review, revise and enforce existing infection prevention and control, and reporting policies.

Regulatory Reporting

• The facility will assure it meets all reporting requirements for suspected or confirmed communicable diseases as mandated under the New York State Sanitary Code (10 NYCRR 2.10 Part 2), as well as by 10 NYCRR 415.19.
• The facility will ensure that it has access to the Health Commerce System (HCS) and other required reporting systems.
• Adequate staff will be provided access to reporting systems and roles shall be assigned.
• The IP/Designee will report using HCS and NHSN or other method as per NYSDOH and/or CMS guidance.

Staff Education

• The facility Infection Preventionist (IP)/Designee shall provide education on Infection Prevention and Control upon hiring of new staff, as well as ongoing education on an annual basis and as needed should the facility experience the outbreak of an infectious disease.
• The IP/Designee shall conduct annual competency-based education on hand hygiene and donning/doffing Personal Protective Equipment (PPE) at an appropriate level for staff.
• The IP/Designee shall provide in-service training for staff on Infection Prevention policies and procedures as needed for event of an infectious outbreak.

Surveillance/Screening

• At daily morning meeting, the IDT team will identify any issues regarding infection control and prevention.
• Residents will be monitored daily or more frequently to identify symptoms associated with infectious agent.
• The facility will screen employees, visitors and vendors in accordance with NYDOH and or CMS regulations.
• Facility acquired infections will be tracked/reported by the Infection Preventionist/Designee.
• Sick calls will be monitored to identify any staff pattern or cluster of symptoms associated with infectious agent.

Testing

• The facility will conduct staff testing, if indicated, in accordance with NYS regulations and/or physician recommendations for a given infectious agent.
• The facility will arrange for necessary laboratory testing for residents and staff as needed.
• The DNS/Designee will check daily for staff and resident testing results and take action in accordance with state and federal guidance.

Signage

• The Infection Preventionist/Designee will ensure that NYDOH and CMS required signage is visible in designated areas.
• The Infection Preventionist/Designee will ensure that appropriate infection prevention and control signage is visible in highly visible areas.

Social Distancing

• The facility will review/revise the policy on communal dining guidelines and recreational activities during a pandemic to ensure that social distancing is adhered to in accordance with NYSDOH and CMS guidance.
• Recreation activities will be individualized for each resident in the event of social distancing.
• The facility will post signage indicating directives for social distancing as per NYSDOH and CMS guidance.
• Residents and staff will be educated and monitored to maintain social distancing between peers.

Environmental Controls

• The facility will conduct cleaning/decontamination in response to the infectious disease utilizing cleaning and disinfection product/agent specific to infectious disease/organism in accordance with any applicable state and federal guidance.
• The facility environmental coordinator shall follow all Department of Environmental Conservation (DEC) and DOH rules for the handling of contaminated waste.
• Areas for contaminated waste are clearly identified as per NYSDOH guidelines and in accordance with all regulations.
• Any staff involved in handling of contaminated product shall be trained in procedures prior to performing tasks and shall be given proper PPE.
• The facility will amend the policy and procedure on biohazardous wastes as needed related to any new infective agents.

Quarantine of Units

• Units will be quarantined in accordance with NYSDOH and CMS guidance.
• Appropriate transmission-based precautions will be adhered to for pandemic infection.
• Appropriate signage shall be posted at on each residents’ door indicating the type of transmission-based precautions that are needed.

Resident Cohorting

• Residents shall be isolated/cohorted based on their infection status in accordance with applicable NYSDOH and CMS guidance.
• The facility will dedicate a wing or group of rooms at the end of a unit in order to cohort residents as necessary.
• The cohort area will be clearly demarcated by usage of signs and other appropriate methods to prevent residents from entering area.
• Sharing of bathroom with residents outside the cohort will be discontinued.
• Appropriate transmission-based precautions will be adhered to for each of the cohort groups as stipulated by NYSDOH.
• Appropriate signage shall be posted at on each residents’ door indicating the type of transmission-based precautions that are needed.
• Staff will be educated on the specific requirements for each cohort group.
• The facility shall attempt to dedicate caregivers assigned to each cohort group and/or for staff to attend to residents in the same cohort before moving to another group.
• Residents that require transfer to another health care provider will have their cohort status communicated to provider and transporter.
• The Administrator/Designee will evaluate cohort needs and capabilities on a regular basis including the following, number of residents per cohort, facility layout and staffing. In the event the facility cannot manage cohorting effectively, the Administrator/Designee will attempt to increase resources and/or discharge residents to an appropriate setting. The Administrator/Designee will notify the regional DOH and local DOH for further assistance if the facility cannot set up cohort areas or can no longer sustain cohorting efforts.

Resident and Family Education

• The Nursing Department/Designee will provide residents and representatives with education about the disease and the facility’s response strategy at a level appropriate to their interests and need for information.
• Residents will receive updated information on the infective agent, mode of transmission, requirements to minimize transmission, and all changes that will affect their daily routines. The facility may utilize the following but not limited to letters, phone, hotline, website, social media and face to face.

Out on Pass

• Out on pass and appointments will be restricted and limited based on NYSDOH and CMS guidance.

Visitation/Vendors

• The facility will implement visitation guidance from NYSDOH and CMS.
• Visitors may be restricted and/or limited as indicated and in accordance with NYSDOH and CMS guidance.
• As appropriate, vendors will be directed to drop off needed supplies and deliveries in designated areas to limit movement in the facility and/or prevent entering the facility.
• Residents, representatives, visitors and vendors will be informed as to visitation restrictions, limitations and guidelines as regulatory changes are made.

Communication

• The Nursing Department/designee will update by telephone, representatives of residents that are infected with the pandemic related infection at least once per day and upon a change in the resident’s condition.
• Administration/designee will at least once a week update residents and resident representatives on the number of infections and deaths at the facility, and not later than five o’clock p.m. the next calendar day following the detection of a confirmed infection of a resident or staff member, or at such earlier time as guidance from CMS. The number that expired will include those that were infected with or resulted from the pandemic-related infection.
• The Social Services Department/Recreation Department will inform residents and their representative of the hotline number or other method to receive pandemic related information.
• Required communications will be by electronic means and the facility will work to accommodate another method selected by a representative.
• The facility will provide all residents with no cost, daily access to remote videoconference or equivalent communication methods with family members and guardians.
• The Recreation Department/designee will assist residents as needed including scheduling calls and providing equipment such as tablets and internet access.
• Consistent with any guidance and regulations issued by the commissioner, the facility will provide residents with access, at no cost, to state long-term care ombudsman program staff and volunteers, and that provides state long-term care ombudsman program staff and volunteers with access to the facility.

PPE, Sanitizer and Disinfectants

• The facility shall maintain at least a two-month (60 day) supply of PPE or any superseding requirements under New York State Executive Orders and/or NYSDOH regulations governing PPE supply requirements executed during a specific disease outbreak or pandemic. In the absence of such guidance the facility with consult the CDC PPE burn rate calculator. Supplies to be maintained include but are not limited to:
  • N95 respirators
  • Face shield
  • Eye protection
  • Gowns/isolation gowns
  • Gloves
  • Masks
  • Sanitizer and disinfectants (meeting EPA Guidance current at the time of the pandemic)
• Supply needs will be based on census, not capacity and will include considerations of space for storage.
• The facility has established par levels for PPE.
• The facility has established par levels for Environmental Protection Agency (EPA) approved environmental cleaning agents based on pandemic usage.
• The Central Supply Coordinator/Designee in coordination with the Director of Nursing, Infection Preventionist, Medical Director, Facilities Manager and other appropriate personnel will review and calculate daily usage/burn rate to ensure adequate PPE is maintained.
• The Central Supply Coordinator/Designee shall establish a schedule for ordering and delivery of supplies. Supply issues such as shortages shall be reported to the Administrator/Designee.
• The facility shall designate a location for the secure storage of supplies.
• The Central Supply Coordinator/Designee shall rotate supplies needed.
• The Central Supply Coordinator/Nursing Supervisor shall ensure adequate and available PPE is accessible on all shifts.
• Hand sanitizer will be available upon entrance to facility and according to NYSDOH and CMS guidance. Daily Housekeeping staff will ensure adequate hand sanitizer and refill as needed.
• The facility shall implement emergency resource management strategies in the event resources are unable to be obtained through regular procurement methods.

Food, Water, Medication, Other Supplies

• The facility has emergency par levels for food, water medication and other supplies.
• The Administrator and appropriate Departments will review and revise as needed with vendors, the facility’s supply arrangements for water, food, medication and other supplies.
• The facility shall implement emergency resource management strategies in the event resources are unable to be obtained through regular procurement methods.

Admissions/Readmissions

• The facility will assure hospitalized residents will be admitted or readmitted to such residential health care facility or alternate care site after treatment, in accordance with all applicable laws and regulations including but not limited to 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415(i); and 42 CFR 483.15(e).
• The facility will preserve a resident’s place in a residential health care facility if such resident is hospitalized, in accordance with all applicable laws and regulations including but not limited to 18 NYCRR 505.9(d)(6) and 42 CFR 483.15(e).
• Prior to admission/readmission the DNS/Designee will review hospital records to determine resident needs and the facility’s ability to provide care including cohorting and treatment needs.
• The Admissions Department will maintain communication with hospitals and the Nursing Department to schedule admissions/readmissions.
• The facility will implement closing the facility to new admissions in accordance with any NYSDOH directives relating to disease transmission.

Recovery/Return to Normal Operations

• The facility will adhere to directives as specified by, State and CMS guidance at the time of each specific infectious disease or pandemic event e.g., regarding how, when, which activities/procedures/restrictions may be eliminated, restored and the timing of when those changes may be executed.
• The facility will communicate any relevant activities regarding recovery/return to normal operations with staff and other relevant stakeholders.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact our Compliance and Ethics Officer.

The name, title, and telephone number of our Compliance and Ethics officer are:
Aliza Klugmann, Compliance Officer, 718-646-5700

1. PURPOSE OF THE NOTICE OF PRIVACY PRACTICESThis Notice of Privacy Practices (the “Notice”) is meant to inform you of the uses and disclosures of protected health information (PHI) that we may make. It also describes your rights to access and control your PHI and certain obligations we have regarding the use and disclosure of your protected health information. Your “protected health information” is information about you created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present, or future physical or mental health or condition, or payment for the provision of your health care. The Privacy Rule, a federal law, gives you rights over your PHI and sets rules and limits as to who can look at and/or receive your PHI. The Privacy Rule applies to all forms of individuals’ PHI, whether electronic, written or oral. The Security Rule is a federal law that requires security for PHI in electronic form. This Notice describes how we may use or disclose your PHI to carry out treatment, payment, or health care operations, as well as other purposes permitted or required by law. We are required by law to maintain the privacy of your protected health information. We are also required by law to provide you with this Notice of our legal duties and privacy practices with respect to your protected health information, to notify you following a breach of your unsecured protected health information, and to abide by the terms of the Notice that is currently in effect. We reserve the right to change the terms of this Notice, at which time, the provisions of the newer Notice will be effective for all PHI that we maintain.
2. UNDERSTANDING YOUR HEALTH RECORD AND INFORMATIONEach time we provide care to you, a record is made containing health and financial information. Typically, this record contains information about your condition, the treatment we provide and payment for the treatment. We may use and/or disclose this information:
   1. to plan your care and treatment
   2. to communicate with other health professionals involved in your care
   3. to document the care you receive
   4. to educate health professionals
   5. to provide information for medical research
   6. to provide information to public health officials
   7. to evaluate and improve the care we provide
   8. to obtain payment for the care we provide
   9. for administrative purposes
3. UNDERSTANDING WHAT IS IN YOUR RECORD AND HOW YOUR PHI IS USED HELPS YOU TO:
   1. ensure it is accurate
   2. better understand who may access your PHI
   3. make more informed decisions when authorizing disclosure to others
4. HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATIONThe following categories describe some of the different ways that we may use or disclose your PHI. Even if not specifically listed below, the facility may use and disclose your PHI as permitted or required by law or as authorized by you. We will make reasonable efforts to limit access to your PHI to those persons or classes of persons, as appropriate, in our workforce who need access to carry out their duties. In addition, if required, we will make reasonable efforts to limit the PHI to the minimum amount necessary to accomplish the intended purpose of any use or disclosure and to the extent such use or disclosure is limited by law.
5. USES AND DISCLOSURES OF YOUR PHI THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION OR OPPORTUNITY TO AGREE OR OBJECT
   1. For Treatment—We may use and disclose your PHI to provide you with medical treatment and related services. For example, we may also use or disclose PHI about you in order to coordinate your care and provide you with medication, lab work, and x-rays. If we are permitted to do so, we may also disclose your PHI to individuals or facilities that will be involved with your care after you leave the Facility and for other treatment reasons. We may also use or disclose your PHI in an emergency situation.
   2. For Payment—We may use and disclose your PHI so that we can bill and receive payment for the treatment and related services you receive. For billing and payment purposes, we may disclose your health information to your payment source, including an insurance or managed care company, Medicare, Medicaid or another third-party payor. For example, we may need to give your health plan information about the treatment you received so your health plan will pay us or reimburse us for the treatment, or we may contact your health plan to confirm your coverage or to request prior authorization for a proposed treatment.
   3. For Health Care Operations— We may use and disclose your PHI for our day-to-day health care operations. This is necessary to ensure that you receive quality care. For example, we may use PHI for quality assessment and improvement activities and for developing and evaluating clinical protocols. We may also combine PHI about many residents to help determine what additional services we should offer, what services should be discontinued, and whether certain new treatments are effective. PHI about you may be used for business development and planning, cost management analyses, insurance claims management, risk management activities, and in developing and testing information systems and programs. We may also use and disclose information for professional review, performance evaluation, and for training programs. Other aspects of health care operations that may require use and disclosure of your PHI include accreditation, certification, licensing and credentialing activities, review and auditing, including compliance and ethics reviews, medical reviews, legal services, and compliance and ethics programs. Your PHI may be used and disclosed for the business management and general activities of our Company including resolution of internal grievances, customer service, and due diligence in connection with a sale or transfer of our Company. In limited circumstances, we may disclose your PHI to another health care provider subject to HIPAA for its own health care operations. We may remove information that identifies you so that the PHI may be used to study health care and health care delivery without learning your identity.
   4. Business Associates—There may be some services provided by our business associates, such as a billing service, transcription company or legal or accounting consultants. We may disclose your PHI to our business associate so that they can perform the job we have asked them to do. To protect your health information, we require our business associates to enter into a written contract that requires them to appropriately safeguard your information.
   5. Providers—Many services provided to you, as part of your care at the Facility are offered by participants in one of our organized healthcare arrangements. These participants may include a variety of providers such as physicians, therapists, psychologists, social workers, and suppliers. We may use and disclose PHI to contact you as a reminder that you have an appointment at a provider.
   6. As Required by Law—We will disclose PHI about you when required to do so by federal, state, or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
   7. Public Health Activities—We may disclose your PHI to prevent a serious threat to your health and safety or the health and safety of the public or another person to a public health authority that is authorized by law to collect or receive such information, such as for the purpose of preventing or controlling disease, injury or disability; reporting births, deaths or other vital statistics; reporting child abuse or neglect; notifying individuals of recalls of products they may be using; notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.
   8. Risk of Contracting a Communicable Disease—We may use or disclose PHI about you if you may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, so long as we are authorized by law to notify you as necessary in the conduct of a public health intervention or investigation.
   9. To Avert a Serious Threat to Health or Safety—We may use and disclose your PHI when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. Any disclosure, however, would be to someone able to help prevent the threat.
   10. Coroners, Medical Examiners, Funeral Directors— We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose medical information to funeral directors as necessary to carry out their duties, as authorized by law.
   11. Organ and Tissue Donation—If you are an organ donor, we may disclose PHI to organizations that handle organ procurement to facilitate donation and transplantation.
   12. Military and National Security—If required by law, if you are a member of the armed forces, we may (1) use and disclose your PHI as required by military command authorities or the Department of Veterans Affairs; (2) disclose your PHI to authorized federal officials for the conduct of lawful intelligence, counter- intelligence, and other national security activities authorized by law (3) disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or conduct special investigations; (4) use and disclose your PHI for the purpose of a determination by the Department of Veterans Affairs, and/or to foreign military authorities if you are a member of that foreign military service, of your eligibility for benefits.
   13. Research Purposes—Your PHI may be used or disclosed for research purposes, but only if the use and disclosure of your information has been reviewed and approved by a special Privacy Board or Institutional Review Board, or if you provide authorization.
   14. Workers’ Compensation—We may use or disclose your PHI as permitted by laws relating to workers’ compensation or related programs.
   15. Health Oversight Activities—We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, accreditation, licensure, and disciplinary actions.
   16. Reporting Abuse, Neglect, or Domestic Violence—We may disclose your PHI to an appropriate government agency if we believe you may have been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
   17. Criminal Activity—We may disclose your PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to health or safety of you, another person or the public. We may also disclosure PHI if it is necessary for law enforcement officials to identify or apprehend an individual.
   18. Legal Proceedings—If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
   19. Law Enforcement—We may disclose PHI when requested by a law enforcement official:
   20. In response to a court order, subpoena, warrant, summons or similar process, or otherwise as required by law;
       1. To identify or locate a suspect, fugitive, material witness, or missing person;
       2. To report gunshot wounds;
       3. To report emergencies or suspicious deaths;
       4. About you, the victim of a crime if, under certain limited circumstances, we are unable to obtain your agreement;
       5. About a death we believe may be the result of criminal conduct;
       6. About criminal conduct at our Company;
       7. In emergency circumstances to report a crime; the location of the crime or victims; and/or the identity, description or location of the person who committed the crime; and
       8. Where there is a medical emergency (not on our Company’s premises) and it is likely that a crime has occurred.
   21. National Security and Intelligence Activities—We may disclose PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
   22. Food and Drug Administration—We may disclose PHI to a person or company required by the Food and Drug Administration (“FDA”) for the purpose of quality, safety or effectiveness of FDA-regulated products or activities including, without limitation, to report adverse events, product defects or problems, or biologic product deviations; to track products; to enable product recalls; to make repairs
       or replacement; or to conduct post marketing surveillance, as required.
6. USES AND DISCLOSURES THAT REQUIRE PROVIDING YOU THE OPPORTUNITY TO AGREE OR OBJECT
   1. Treatment Alternatives and Other Health-Related Benefits and Services—We
      may use and disclose PHI to tell you about or recommend possible treatment options or alternatives and to tell you about health-related benefits, services, or medical education classes that may be of interest to you.
   2. Fundraising Activities—We may use information about you to contact you in an effort to raise money for the Facility and its operations. For the same purpose, we may share your information with our institutionally related foundation. The information we use or share will be limited to your name, address, other contact information, age, gender, date of birth, dates that you received health care, department of service information, treating physician, outcome information, and health insurance status. You have the right to opt out of receiving such communications. A description of how to opt out of any fundraising communications will be included in any fundraising materials or communications that you receive. If you request that your information not be used or disclosed for fundraising purposes, we will make sure that you do not receive future fundraising communications. We may provide with you a method to opt back in to receive such communications.
   3. Facility Directory—Except for individuals admitted to a hospital for psychiatric disabilities or to a substance abuse treatment program, unless you object, we may include limited information about you in our facility directory while you are a resident at the facility, including your name, location in the facility, your general condition (e.g. fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your information and religious affiliation may also be given to a member of the clergy, even if the clergy member does not ask for you by name.
   4. Individuals Involved in Your Care or Payment of Your Care—Unless you object, we may disclose your PHI to a family member, a relative, a close friend or any other person you identify, if the information relates to the person’s involvement in your health care to notify the person of your location or general condition or payment related to your health care. In addition, we may disclose your PHI to a public or private entity authorized by law to assist in a disaster relief effort. If you are unable to agree or object to such a disclosure, we may disclose such information if we determine that it is in your best interest based on our professional judgment or if we reasonably infer that you would not object.
7. USES AND DISCLOSURES OF PHI BASED UPON YOUR WRITTEN AUTHORIZATION
   1. All other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke your written authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures we have already made with your authorization.
   2. Uses and Disclosures of Psychotherapy Notes—Psychotherapy notes are notes (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and a summary of the following: diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes will not be used or disclosed without a valid, written authorization, except to carry out the following treatment, payment, or health care operations:
      1. Use by the originator of the psychotherapy notes for treatment;
      2. Use or disclosure by the Facility for its own training programs in which students, trainees, or practitioners in mental health learn, under supervision, to practice or improve their skills in group, joint, family, or
         individual counseling; or
      3. Use or disclosure by the Facility to defend itself in a legal action or other proceeding brought by the patient; and
      4. A use or disclosure that is required by or permitted by the applicable regulations, including disclosure to the Secretary and as otherwise required by law.
   3. Use and Disclosure of Substance Abuse and HIV-Related Information—For disclosures concerning PHI relating to care for substance abuse or HIV-related testing and treatment, special restrictions may apply. For example, we will generally not disclose this specially protected information unless you sign a specific authorization, or a court orders the disclosure.
      1. Substance abuse treatment information. If you are treated in a specialized substance abuse program, the confidentiality of alcohol and drug abuse patient records is protected by federal and state laws and regulations. Generally, we may not say to a person outside the program that you attend the program, or disclose any information identifying you as an alcohol or drug abuser, unless:
         1. You consent in writing
         2. The disclosure is allowed by a court order; or
         3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation
   4. Marketing—A signed authorization is required for the use or disclosure of your PHI for a purpose that encourages you to purchase or use a product or services except for certain limited circumstances, such as when the marketing communication is face-to-face or when marketing includes the distribution of a promotional gift of nominal value provided by the Facility. An authorization is not required to describe a health-related product or service provided by use; to make communications to you regarding your treatment; or to direct or recommend
      alternative treatments, therapies, providers, or settings of care for you.
   5. Disclosures that Constitute a Sale of PHI—A signed authorization is required for the use or disclosure of your PHI in the event that the Facility directly or indirectly receives remuneration for such use or disclosure, except under certain circumstances as allowed by federal or state law. For example, authorization is not needed if the purpose of the use or disclosure is for your treatment, public health activities, or providing you with a copy of your PHI.
8. WHEN WE MAY NOT USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
   1. Except as described in this Notice, or as permitted by state or federal law, we will not use or disclose your PHI without your written authorization.
   2. Your written authorization will specify particular uses or disclosures that you choose to allow. Under certain limited circumstances, the Facility may condition treatment on the provision of an authorization, such as for research related to treatment. If you do authorize us to use or disclose your PHI for reasons other than treatment, payment, or health care operations, you may revoke your authorization in writing at any time by contacting the Facility’s Compliance and Ethics Officer. If you revoke your authorization, we will no longer use or disclose your PHI for the purposes covered by the authorization, except where we have already relied on the authorization.
9. RIGHT TO REQUEST RESTRICTIONS ON CERTAIN USES AND DISCLOSURES
   1. You have the right to request a restriction or limitation on the PHI we use or disclose about you, including information used or disclosed for the purposes of treatment, payment, or health care operations. You may also request that your PHI not be disclosed to family members or friends who may be involved in your care.
   2. You may request a restriction on the use or disclosure of your PHI by submitting a written request to the Facility stating (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply.
   3. We are not required to agree to your requested restriction, unless it involves the disclosure of PHI to a health plan for purposes of carrying out payment or health care operations that pertains solely to a health care item or service for which the
      Facility has been paid out of pocket in full by you or a third party (other than the health plan) on your behalf.
   4. If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you with emergency treatment. If restricted PHI is disclosed to a health care provider for emergency treatment, we will request that such health care provider not further use or disclose the information. In addition, you and the Facility may terminate the restriction if the other party is notified in writing of the termination.
10. RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATIONS AND/OR ALTERNATE COMMUNICATIONS—You have the right to request a reasonable accommodation regarding how you receive communications of PHI. You have the right to request an alternative means of communication or an alternative location where you would like to receive communications. For example, you may ask that we only contact you via mail to a post office box. We will not request an explanation from you as to the basis for the request. You must submit your request in writing to our office. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.
11. RIGHT TO ACCESS, INSPECT, AND COPY YOUR PHI—You have the right to access, inspect, and obtain a copy of your PHI that is used to make decisions about your care for as long as the PHI is maintained by the Facility. You may not be permitted to inspect or copy the following: psychotherapy notes, or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding. If we maintain your information electronically in a designated record set, then you have the right to request an electronic copy of such information. To access, inspect, and copy your PHI that may be used to make decisions about you, you must submit your request in writing to the Facility. If you request a copy of the information, we may charge a fee for the costs of preparing, copying, mailing, or other supplies associated with your request. We may deny, in whole or in part, your request to access, inspect, and copy your PHI under certain limited circumstances. If we deny your request, we will provide you with a written explanation of the reason for the denial. You may have the right to have this denial reviewed by an independent health care professional designated by us to act as a reviewing official. This individual will not have participated in the original decision to deny your request. You may also have the right to request a review of our denial of access through a court of law. All requirements, court costs, and attorneys’ fees associated with a review of denial by a court are your responsibility. You should seek legal advice if you are interested in pursuing such rights.
12. RIGHT TO AMEND YOUR PHI—You have the right to request an amendment to your PHI for as long as the information is maintained by or for the Facility. Your request must be made in writing to the Facility and must state the reason for the requested amendment. We may not accept your request for an amendment if the request is not in writing or does not include a reason to support the request. We may deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the PHI kept by or for the Facility; or (3) is accurate and complete.
    1. If we deny your request for amendment, we will provide you with a written denial including the reasons for the denial and information on the right to submit a written statement disagreeing with the denial. We may rebut your statement of disagreement. If you do not wish to submit a written statement disagreeing with the denial, you may request that your request for amendment and your denial be disclosed with any future disclosure of your relevant information.
13. RIGHT TO RECEIVE AN ACCOUNTING OF DISCLOSURES OF PHI—You have the right to receive an accounting of certain disclosures of your PHI by the Facility or by others on our behalf. To request an accounting of disclosures, you must submit a request in writing, stating a time period that is within six (6) years from the date of your request. The first accounting provided within a twelve-month period will be free. We may charge you a reasonable, cost-based fee for each future request for an accounting within a single twelve-month period. However, you will be given the opportunity to withdraw or modify your request for an accounting of disclosures in order to avoid or reduce the fee. In the event the Facility maintains an electronic health record, an accounting of disclosures from the electronic health record related to treatment, payment or health care operations will be made only for the three (3)-year period preceding the request.
14. RIGHT TO BE NOTIFIED FOLLOWING A BREACH OF UNSECURED PHI—If there is a breach to your PHI, you will be notified within a reasonable amount of time, as required by law.
15. RIGHT TO A REVISED COPY OF THIS NOTICE—Upon request, you have the right to receive a copy of revised Notices on or after the effective date of revision. Additionally, the revised Notice will be posted in a clear and prominent location.
16. RIGHT TO OBTAIN A PAPER COPY OF NOTICE—You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting the facility. In addition, you have the right to receive a copy of this Notice when the Facility seeks additional consent.
17. RIGHT TO COMPLAIN—You may file a complaint with us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may also file a complaint with us by notifying our Compliance and Ethics Officer in writing of your complaint. You will not be penalized or retaliated against for filing a complaint and we will make every reasonable effort to resolve your complaint with you.

Disclosures

Vendors:

A+ Fire Control Ltd.	Filta Kleen	Mature Solutions, Inc.	Ronbar Laboratories, Inc.
Abaline	First Insurance Funding Corp.	Medcare Marketing & Consulting	S & S Worldwide, Inc.
Ability Network Inc.	Fiveboro Printing & Supplies	Medline Industries, Inc.	S. J. Fuel Co., Inc.
Abrams, Fensterman, LLP	Flexfacts Grant Benefits Solut	Med Part	Sacredness
Advanced Medical Staffing / Promed	Florida State Disbursment Unit	Metlife	Saps Drug Wholesale
Aflac New York Corporate	Franczoz Kosher Bakery	National Care Systems, LLC	Sbv Workfors Management
Agile Premium Finance	Freedom Center of Kew Gardens	National Grid	Setha Samaritan Inc.
Alburdan Electric Co, Inc.	Martin Friedman	Nationwide Ins. Co.	Sewer King Co.
AliMed, Inc.	Furman Feiner Advertising	Net Health Systems, Inc. / Optima Healthcare Solution	Shelterpoint Life Insurance Co.
All One Source Supplies, Inc.	FedEx	Netsmart Technologies Inc. / Simpleltc, LLC	Sheppard Mullin Richter & Hampton LLP
All State Pest Management	G & G Duct Cleaning, Inc.	NYC Fire Department	Signature Elevator Maintenance, Inc.
Alle Processing Corp.	Gallagher Basset Services, Inc.	NYC Water Board	Solamed O2 LLC.
Allied Food Products Inc.	Geri Medix, Inc.	NYS Assessment Receivables	Specialty Rx
Allstate Medical	Gianvito Bottalico International Songs	NYS Dept. of Environmental Conservation	Spectrotel
Alrite Packaging, Inc.	Global Tech Solutions	New York State Department of Health	Striv360
Amtrust North America, Inc.	Goldburd Mccone LLP	NYS DOH Bureau of Narcotic Enforcement	Sunoco
An Construction Co.	Grainger	NYU Physician Services	Swift Staffing
Apploi Corp.	Grandison Management	Abiodun Oloyede	Techradium
Approved Admissions, LLC	Graph Insurance Group	On Time Rooters Inc.	Teller Printing
Approved Storage & Waste Hauling	Greater NY Health Care Facility Assn.	On.Care, LLC	The Charts Group
S. Bertram Inc.	Harbor Care, LLC	Optimum	Therapeutic Resources
BK Appliances Inc.	Hashgacha Kahalacha	P & G Insurance Brokers	Tikva Security, LLC
Brand Right Marketing Group	Health Facility Assessm. Fund	Pacific Interpreters, Inc.	Toner Quest
The Cbord Group, Inc.	Health Pass New York	People Systems	Tool House Rental
Centers Laboratory / Modern Diagnostic	Health Reimbursement Account	Perfect Gift LLC	Towne Nursing Staff, Inc.
Chase Card Services	Helpful Hounds LLC	Perks	MBS Ltd./Tri State Surgic. Sup & Equip. Ltd.
Cicero Consulting Associates	Heyframes	Personal Touch Health Care	Uni Systems of NY, Inc.
Citi Security Inc.	Hiring 4 Less	Pharmacon Corp.	United Laboratories
Commercial Readers Service	Hobby Office Corp.	Pinnacle Prescription Analysis	Upstate Dairy Farms
Competent Nursing Agency LLC	Holistic Transportation	Pitney Bowes Global Financial Svc. Inc.	Venture Respiratory Inc.
Compliance Consulting Group LLC	ICNYHH, Inc.	Pitney Bowes Purchase Power	Verizon
Con Edison	Industrial Chem Labs	Power House Generators	Vertical Staffing
Confidence Management System	Innovative Supply Group	Precision Health, Inc.	Well Being Physical
Corner Hardware & Paint Center	Intac	Prestige Point Design	William Hird & Co., Inc.
Crumiller P.C.	Isaac Refrigeration & Sons Inc.	Prime-Tex Industries	Windstream Enterprise
Cushman & Wakefield	Island Plumbing & Heating Supp	Print It	Wright National Flood Insur. Co.
Daily News	Jenmar Storefronts/Doors/Glass	Prionsafe, LLC	Zoll Services, LLC
Daymark	KCI USA	Pro Benefits Administrators
Dentserv Dental Services, P.C.	Kimtech Services LLC	Pro-Plus
E.N.Y. Communications	Kinney Services, Inc.	Progressive Casualty Insurance
Empeon -5005SN (Payroll Taxes)	Klear View Appliance	Promotion Depot
Empro Staffing	Klein’s Real Kosher Ice Cream	Public Storage 29206
Envirogreen Solutions Inc.	Lipkaw Realty, LLC	Quality Renal Consulting LLC
Enyq Corp. Plumbing & Heating Co.	M & M Frankel Disposables Inc.	RDE Technologies
Essex Temporary Services, Inc.	M & M Health Care Apparel Co.	Regency Recycling Corporation
Exclusive Nursing Staff Inc.	Macquarie Equipment Capital Inc.	Regency Telecom Inc.
F & L Construction & Roofing	Marble Music	Reliable Health Systems, LLC
Feldman, Kramer & Monaco, P.C.	MassMutual Financial Group	RES Systems
Fidelity Payment Services	Master Fire Systems, Inc.	Rise Elevator Inspections
Filescan Solutions	MatrixCare	Ronald Moses Badge No.10

Premises Landlord:

Lipkaw Realty, 2840 Knapp Street, Brooklyn NY 11235

Facility Owners:

The following people are the registered owners the facility: Olga Lipschitz, Edith Wieder, Pearl Kahan, Jerome Kahan, Morton Paneth, Thomas Paneth, Leah Werner, Elliot Lipschitz, Howard Lipschitz, Samuel Lipschitz.

Maximum Non-Governmental Payer Rates:

Maximum Private Pay Rate: $550 per day

Maximum Insurance Rate is $750 per day

Maximum Rates Per Insurance:

Aetna	$400
Affinity	$650
Amerigroup (Anthem)	$560
Amida	100% Medicaid Rate
Amida	100% SNFPPS Rate
Cigna	$650
FIDA	100% CMS rate
Elderserve	100% Medicare rate
Empire BCBS Medicare	100% CMS
Empire BCBS Comm.	$675
Hamaspik Medicaid	100% Medicaid Rate
Hamaspik Medicare	$700
ILS Extended MLTC	100% Medicaid Rate
Integra	Medicaid rate + unfunded portion of NY Medicaid per diem assessment
MetroPlus	$520
Senior Whole Health	$450
Village Care Max	100% Medicaid Rate
Wellcare	$600