At its February 2017 policy meeting, the Commission on Accreditation (CoA) approved a revision to the Implementing Regulation D.3-8: Access to Confidential Files by CoA/Site Visitors. Of particular note, the revised Implementing Regulation (IR) indicates that programs should not share Protected Health Information (PHI) with site visitors. While it remains understood that in carrying out the duties and responsibilities of a site visitor, one may accidentally encounter certain patient/client information that is confidential in nature, it is the expectation that programs will not intentionally share PHI information with the team. The Site Visitor Confidential Agreement, signed by all site visitors prior to a visit, reflects this revision.
The following excerpt outlines the expectations of the new Agreement:
- During the accreditation review process, I may incidentally come in contact with PHI.
- I agree that if I incidentally receive PHI during the accreditation review process, I will immediately notify the APA Office of Program Consultation and Accreditation and the Program, and follow their instructions as to whether I should return or destroy the PHI.
- While any Program PHI is in my possession and control, I agree that I will use reasonable and appropriate safeguards to prevent any use or disclosure of the PHI, except as specifically requested by APA or the program, as long as such use or disclosure is consistent with the Health Insurance Portability and Accountability Act, and other applicable laws.
- I agree that I will not make a duplicate copy of, or by any other means record, any PHI.
- I agree to the extent practicable to mitigate any harmful effect known to me of a use or disclosure of PHI in violation of this Confidentiality Agreement.
- Finally, I agree to immediately notify the APA Office of Program Consultation and Accreditation and the Program of any use or disclosure of PHI not permitted by this Confidentiality Agreement of which I become aware.
As always, site visitors will be provided this agreement as part of the visit materials; however, the American Psychological Association, Commission on Accreditation, Site Visitor Confidentiality Agreement can be found in its entirety by visiting the Site Visitors section of the Office of Program Consultation and Accreditation website.