West Virginia Neonatal Abstinence Syndrome Care Plans: Privacy Laws Checklist

A neonatal abstinence syndrome (NAS) care plan should give the care team the clinical details needed to support the newborn while keeping the infant’s information distinct from a parent’s substance use disorder treatment records. Use this checklist to identify what belongs in the plan, when information may be shared, and where West Virginia and federal privacy rules set limits.

What information belongs in a neonatal abstinence syndrome care plan?

Include information that supports assessment, treatment, discharge planning, and follow-up. West Virginia law identifies services at neonatal abstinence centers such as medication, symptom scoring and monitoring, nursing care, nutrition management, doctor visits, and parental training; these are useful care-planning areas, not a single mandatory statewide form. See West Virginia Code §16B-21-1.

• Infant and care-team details: Identify the newborn, responsible clinicians, and the people involved in care coordination.
• Clinical assessment: Record the diagnosis or reason for monitoring, symptoms, assessment method and results, and relevant changes over time.
• Treatment and response: Document medication, dose and response, supportive care, feeding and nutrition needs, and any changes to the treatment plan.
• Caregiver involvement: Note education, parental training, caregiving participation, and the instructions provided for care after discharge.
• Transition and follow-up: Include discharge needs, referrals, appointments, and who is responsible for follow-up.

Keep the plan focused on the newborn’s care. Include information about a parent only when it is relevant and permitted to support the infant’s treatment or care coordination; do not treat the parent’s substance use disorder treatment record as part of the newborn’s chart by default.

Which West Virginia and federal privacy laws apply?

The HIPAA Privacy Rule governs protected health information (PHI) held by covered health care providers and other covered entities. It permits certain uses and disclosures, including for treatment, while limiting disclosures to those allowed or required by the rule. See 45 CFR 164.502.

42 CFR Part 2 adds protections for qualifying substance use disorder treatment records maintained by a federally assisted Part 2 program. Its protections depend on the record’s origin and whether it identifies someone as a patient of such a program; a newborn’s NAS chart is not automatically a Part 2 record simply because it documents substance exposure. The current Part 2 requirements had a compliance date of February 16, 2026. See 42 CFR 2.12 and the HHS Part 2 final rule fact sheet.

For a West Virginia medical records confidentiality checklist, distinguish rules about access to records from rules permitting disclosure to others. West Virginia law addresses parental access to a minor’s health records, subject to specified exceptions; that access rule is not a blanket authorization to share records with an unrelated person or agency. See West Virginia Code §16-29-3. Separately, records held by the West Virginia Department of Human Services and other listed child-welfare entities are generally confidential, with statutory exceptions. See West Virginia Code §49-5-101.

When may care teams share information without authorization?

Under HIPAA, covered providers may disclose PHI to other health care providers for treatment without a separate authorization. The minimum-necessary standard does not apply to provider-to-provider disclosures for treatment, though organizations should still use appropriate safeguards and follow applicable policies. See HHS guidance on treatment disclosures and HHS guidance on the minimum-necessary standard.

Under 45 CFR 164.512, HIPAA also permits a covered entity to report suspected child abuse or neglect to a government authority authorized by law to receive the report. In West Virginia, mandated reporters—including medical professionals—must report when they have reasonable cause to suspect that a child is abused or neglected, immediately and no later than 24 hours after suspecting it. See West Virginia Code §49-2-803.

West Virginia Department of Human Services policy describes a Plan of Safe Care for infants exposed to or affected by substances, including prescribed medication, and says that such exposure does not mean every infant has been maltreated. Its policy gives a hospital CPS referral as an example even where medication was prescribed and no maltreatment was found. Distinguish that referral and Plan of Safe Care process from the statutory threshold for a mandated abuse-or-neglect report. See the West Virginia CPS Policy, revised July 2025 and West Virginia Code §49-1-201.

How should parental consent and releases be documented?

Separate consent for the newborn’s treatment from consent for disclosure of information. A parent or legal guardian is generally the newborn’s HIPAA personal representative, subject to applicable law and exceptions. West Virginia law generally allows a parent or guardian to access a minor’s health records without the minor’s separate permission, but that does not itself authorize every external disclosure. See HHS guidance on personal representatives and minors and West Virginia Code §16-29-3.

When an authorization is needed, document the person whose information is being disclosed, who may receive it, the information covered, the purpose, and the authorization’s expiration or revocation terms. For consent for disclosure of protected health information under HIPAA, follow the applicable authorization requirements in 45 CFR 164.508.

For Part 2 records, the patient’s consent must meet Part 2’s specific requirements, including identifying the patient, the information, the recipient or recipient class, the purpose, and the expiration terms, as well as signature and date. Current rules permit a single consent for future treatment, payment, and health care operations disclosures when it meets the rule’s requirements. If the disclosure concerns an adult parent’s own substance use disorder treatment records, the parent—not someone signing only as the newborn’s representative—must provide any required consent for those records. See 42 CFR 2.31.

What records and disclosures must be protected?

Protect identifiable information about the newborn, including NAS assessments, laboratory results, diagnoses, medications, progress notes, and discharge plans, as PHI when held by a HIPAA-covered entity. Information in the newborn’s chart may also reveal sensitive facts about a parent, so check whose information is being disclosed and the legal basis for sharing it.

Protect substance use disorder treatment records covered by Part 2 separately. Do not assume that an infant’s chart gives the care team permission to access or disclose a parent’s Part 2 records. A Part 2 record shared under a qualifying treatment, payment, and health care operations consent may be redisclosed by a HIPAA-covered recipient as HIPAA permits, but Part 2 continues to restrict use or disclosure in proceedings against the patient. See HHS guidance on Part 2 records.

For disclosures that are subject to HIPAA’s minimum-necessary rule, limit information to what is reasonably needed for the purpose. HIPAA exempts provider-to-provider disclosures for treatment from that standard, but the exemption does not remove the need to protect records from access or disclosures that are not otherwise permitted.

What are the limits of confidentiality when reporting is required?

West Virginia mandatory reporting applies when a mandated reporter has reasonable cause to suspect abuse or neglect; a newborn’s substance exposure alone should not be treated as a finding of maltreatment. The state’s definition includes parental substance use that impairs parenting skills to a degree posing an imminent risk to the child’s health or safety. See West Virginia Code §49-2-803 and West Virginia Code §49-1-201.

HIPAA permits reporting suspected child abuse or neglect to an authorized government authority without the individual’s authorization. Part 2 also permits reporting incidents of suspected child abuse and neglect when reporting is made under state law, but the exception does not make the original Part 2 treatment records freely available for later civil or criminal proceedings arising from the report. See 45 CFR 164.512 and 42 CFR 2.12.

In practice, keep the infant’s care plan clinically useful, verify the applicable authority before sharing, document consent or the legal basis for a disclosure, and keep the parent’s Part 2 records distinct from the newborn’s PHI.

FAQs

Does a neonatal abstinence syndrome care plan require parental consent to share information?

No blanket parental consent is required for every disclosure. HIPAA permits provider-to-provider sharing for treatment and permits certain reports to authorized child-protection authorities. Sharing a parent’s Part 2 substance use disorder treatment records is a separate question and may require the parent’s consent or another specific Part 2 exception.

Can West Virginia providers disclose NAS information to child welfare agencies?

Yes, when disclosure is permitted or required under the applicable rules. HIPAA permits child-abuse or neglect reports to an authorized government authority, and West Virginia law requires mandated reporters to report suspected abuse or neglect within the statutory timeframe. West Virginia Department of Human Services policy also describes CPS referrals and Plans of Safe Care for substance-exposed infants; a referral is not, by itself, a finding of maltreatment.

Does HIPAA protect a newborn’s substance exposure information?

Yes. When the information is identifiable and held by a HIPAA-covered entity, it is the newborn’s PHI and is protected by the HIPAA Privacy Rule. Part 2 does not automatically apply to the newborn’s chart solely because it mentions substance exposure; its applicability depends on whether the record meets Part 2’s requirements for records identifying a patient of a qualifying program.

When can substance use disorder treatment records be disclosed without written consent?

Part 2 allows certain disclosures without written consent in specific circumstances, including a bona fide medical emergency, reporting suspected child abuse or neglect under state law, certain communications within a Part 2 program, and certain audits or evaluations. A court-authorized disclosure may also be possible when Part 2’s requirements are met. These exceptions are limited; they do not create general permission to disclose a patient’s substance use disorder treatment records.