North Adams Home

Policy and Procedure


Policy: NAH will make reasonable efforts to limit the protected health information (PHI) to the minimum necessary to accomplish the intended purpose of the use, disclosure or request.



If a request is made for PHI- NAH will disclose the amount of information that the requester needs to know to carry out his/her responsibility.


Paper Shredding:

  • All papers with resident names or PHI will be shredded or placed in a container for outside facility shredding
  • All papers with employee PHI will be shredded or placed in a container for outside facility shredding
  • Special shred boxes will be in each office and nursing station in a secure place or shredders may be used
  • Shed boxes will be collected when full by nursing personnel on units, housekeeping and/or office personnel and placed in the secure container for outside of the building shredding

Medical Records:

  • The door to medical records will be locked anytime the area is unattended
  • Key to medical records will be maintained by DON/ADON/Administrator and Transportation Coordinator ( who serves as the medical records designee)
  • Older medical records are kept in the basement of the dental office building with the same staff having access to keys

Transportation of Medical Records:

  • Any PHI being transported to another entity will be transported in a sealed envelope or container and given only to authorized personnel by the transporter or resident/resident’s responsible party
  • Only necessary information will leave the facility 

Fax machines

  • All fax machines will be located in secure areas
  • All incoming fax machines will be checked frequently and faxes removed and distributed to the appropriate personnel

Copy machines

  • Are located in the HR office and the South nurses station
  • Materials copied on the South/SCU machines will not be left unattended