David C. Marshall, Esq. PACAH 2017 Spring Conference April 27, 2017
|
|
- Harvey Poole
- 6 years ago
- Views:
Transcription
1 David C. Marshall, Esq. PACAH 2017 Spring Conference April 27, 2017
2 Privacy and security of patient information held by health care providers remains a concern of the federal government. More resources than ever are directed toward ensuring privacy and security of PHI. Increased penalties for violations, availability of whistleblower benefits, increased audits by the government. It s imperative for providers to secure patient information in their possession
3 HITECH Act Became law in 2009, but implementing regulations were not finalized until Compliance with the various requirements of the Act by September 23, 2013 The major change contained within HITECH dealt with the government s decision to place affirmative obligations on Covered Entities to advise patients when their information has been breached, and to self-disclose those breaches to the government
4 Review requirement to report breaches under HITECH Act Determine whether a reportable breach has occurred Review procedures for reporting a breach Understand new enforcement initiatives from Government and major risk areas for providers Discuss ways to minimize the occurrence of breaches
5 Basic Privacy Rule Unless required or allowed by law, disclosure of protected health information (PHI) is permitted only with consent or authorization of the patient. Examples of PHI Name Social security number Address Date of birth Photograph/Video/Image Health information in medical record PHI includes many common identifiers Includes Medicare number of patient
6 Breach Notification HITECH requires covered entities to notify individuals if their unsecured PHI has been breached Key terms Breach: the unauthorized acquisition, access, use, or disclosure of PHI which compromises the security or privacy of the PHI Unsecured PHI: PHI that isn t secured through use of a technology or methodology specified by the Secretary of Health or Human Services (i.e. Encryption of electronic PHI) Doesn t apply to PHI that has been secured!
7 Breach analysis Breach is presumed Unless there is a low probability that PHI was compromised Analysis is highly-fact specific Must address, at a minimum, the following four factors: 1. Nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification; Did the disclosure involve information that is of a more sensitive nature (financial information, such as SSN or credit card numbers, or clinical information, such as diagnosis or test results)? 2. Unauthorized person who used the PHI or to whom the disclosure was made; Was the disclosure made to another covered entity or business associate?
8 Breach analysis, continued Factors: 3. Whether PHI was actually acquired or viewed; and Or did there only exist an opportunity to view or acquire? 4. The extent to which any risk to PHI has been mitigated Was the information retrieved or were satisfactory assurances requested/received? Document, document, document! If you are going to conclude that no breach has occurred, then you must be able to support that determination
9 Exceptions - a breach does not include: Unintentional acquisition, access or use of PHI by a workforce member E.g., nurse mistakenly sends a billing employee an with resident PHI; Contrast - receptionist decides to look through a patient s file to learn of her friend s treatment An inadvertent disclosure to another authorized person at the same covered entity or business associate Disclosure where the covered entity or business associate had a good-faith belief that the unauthorized person to whom the information was disclosed would not reasonably be able to retain such information. E.g., nurse mistakenly hands a patient the discharge papers belonging to another patient, but she quickly realizes the mistake and recovers the PHI from the patient If it fits within an exception, then it s not a breach and therefore not reportable
10 Breach Notification Send individual notice of breach via first-class mail or e- mail (if individual specifies as a preference) within 60 days from the date the breach is discovered Special rules for big breaches involving 500 or more individuals Notice to media Must notify the Secretary of all breaches true selfreporting! Timing varies depending on the number of individuals affected: 500 or more notify within 60 days Less than 500 within 60 days of the end of the calendar year in which breach was discovered Notice is to be provided using online tool found on OCR website
11 Breach Notification Notice must written in plain language and must contain: Brief description of what happened, including the date of breach and date of discovery Description of the types of unsecured PHI that were involved in the breach Any steps individuals should take to protect themselves from potential harm resulting from the breach Brief description of what the covered entity is doing to investigate the breach, mitigate the harm to the individual, and protect against further breaches Contact procedures for individuals to ask questions or learn additional information, which must include a toll-free number, an address, Web site, or postal address
12 Nurse takes unauthorized photograph of resident and posts it on social media Note potential abuse impact under Survey & Certification Letter S&C: NH Resident documentation is mailed to erroneous address To another health care provider? To a private individual Facility posts/uses picture/video of resident in marketing materials or other publications without Authorization
13 Loss/theft of laptop or cell phone containing resident information Hacking of s or computer systems of provider Improper access of resident PHI by persons not authorized to view Discussions of resident PHI in presence of third parties
14 HHS Office of Civil Rights (OCR) responsible for HIPAA enforcement OCR conducts investigations based on received complaints and through its own compliance reviews of covered entities Since the compliance date of April 2003, OCR has received over 125,641HIPAA complaints. OCR resolved 96% of complaints received: through investigation and enforcement through investigation and finding no violation; through early intervention and providing technical assistance without the need for investigation and through closure of cases that were not eligible for enforcement
15 The compliance issues investigated most are, compiled cumulatively, in order of frequency: Impermissible uses and disclosures of PHI; Lack of safeguards of PHI; Lack of patient access to their PHI; Lack of administrative safeguards of electronic PHI; and Uses or disclosures of more than the minimum necessary PHI The most common types of covered entities that have been required to take corrective action to achieve voluntary compliance are, in order of frequency: Private Practices; General Hospitals; Outpatient Facilities; Health Plans (group health plans and health insurance issuers); and, Pharmacies
16 HITECH requires HHS to conduct periodic audits to ensure covered entities and business associates are complying with the HIPAA Privacy and Security Rules and Breach Notification standards. Phase 1 Audits OCR piloted a program to perform 115 audits of covered entities to assess privacy and security compliance. Audits conducted during the pilot phase began November 2011 and concluded in December
17 Phase 2 Audits July 11, 2016 OCR selected 167 covered entities and business associates for audit; Ultimately, entities will be selected for audit Primarily desk audits, but some site reviews OCR will review policies, procedures, training materials; Focusing on: Notice of Privacy Practices Right to Access Policy Breach Notification (timeliness and content of notice) Security Rule Risk Analysis and Risk Management Training on policies and procedures Device and media controls On-site audits to begin in early
18 Notable Settlements Memorial Healthcare System, a nonprofit health system with 6 hospitals, paid $5.5 million to resolve issues relating to the impermissible disclosure of PHI of 115,143 individuals had been inappropriately accessed by its current and former employees Login credentials of a former employee not changed, so PHI was inappropriately accessed externally and internally MHS had no procedures regarding termination of access to information upon cessation of employment
19 Notable settlements New York and Presbyterian Hospital and Columbia University Disclosure of ephi of 6,800 individuals resulting from a physician attempting to deactivate a personally-owned computer server on the network In addition to the impermissible disclosure, OCR also found that neither entity Made efforts prior to the breach to assure that the server was secure and that it contained appropriate software protections Conducted an accurate and thorough risk analysis and therefore neither had developed an adequate risk management plan that addressed potential threats to security of ephi $4.8 million settlement
20 Notable settlements, continued Dermatology practice Unencrypted thumb drive containing ephi of approximately 2,200 individuals was stolen from staff member s vehicle OCR found that the practice: Hadn t conducted an accurate and thorough analysis of the potential risk to the confidentiality of ephi and Didn t comply with the requirements of the Breach Notification Rule to have in place written policies and procedures to train workforce members $150,000 settlement
21 Notable settlements, continued Idaho State University Breach of ephi of approximately 17,500 patients, which was unsecured for at least 10 months due to the disabling of firewall protections on the servers $400,000 settlement Hospice provider Unencrypted laptop containing ephi of 441 patients had been stolen OCR found that the provider hadn t conducted a risk analysis to safeguard ephi and didn t have policies or procedures to address mobile device security First settlement involving a breach of ephi affecting fewer than
22 Use of mobile devices is a big risk area HHS/OCR Wall of Shame shows that since the breach reporting requirement became law, 372 reported thefts or losses of laptops or other portable electronics HHS/OCR takes particular interest in these types of cases In 2014, Concentra paid HHS $1,725,220 to resolve potential violations stemming from stolen, unencrypted laptop OCR says, Encryption is your best defense
23 What is it? Method of converting an original message of regular text into encoded text. The text is encrypted by means of an algorithm (type of formula). If information is encrypted, there would be a low probability that anyone other than the receiving party who has the key to the code or access to another confidential process would be able to decrypt (translate) the text and convert it into plain, comprehensible text. If PHI is encrypted, there is no breach and no breach notification is required
24 BUT, encryption is not mandated by the Security Rule. The encryption implementation specification is addressable meaning it must be implemented if reasonable and appropriate If it s not, then must choose another alternative that is reasonable and appropriate Cost issues!
25 Perform an annual risk assessment OCR has published a security risk assessment tool, available at its website. Designed to help providers conduct and document a risk assessment in a thorough, organized fashion at their own pace by allowing them to assess security risks in their organizations Allows providers to uncover potential weaknesses and address vulnerabilities, potentially preventing data breaches or other adverse security events
26 Update policies and procedures, as needed, and train staff on any changes If HIPAA policies/procedures were last updated before 2009, they are not compliant Consider encryption of electronic transmissions, mobile devices and media containing electronic protected health information, particularly USB/thumb drives. Before sending a Fax containing PHI, confirm that the recipient is authorized to receive PHI Evaluate your mobile devices, data destruction, and data transmission policies and practices Educate employees on not leaving electronic devices or paper records unattended
27 Laptops, ipads and Smart Phones All devices should have passwords Do not store PHI on the hard drive of device Do not leave in car or unattended Immediately report theft or loss Must be able to erase access to /records system, and be able to determine if anyone can gain access to PHI through the device Can you remotely wipe the lost/stolen device? This is the #1 type of HIPAA violation being enforced now
28 Avoid Unintended Disclosures Do not leave PHI open on desk for non-facility personnel to view Do not leave PHI open on your computer for nonfacility personnel to view turn off at night Lock office doors at night if leaving PHI out; File PHI so it s not left open on desks Make sure computer is password protected; If viewing PHI on screen, make sure to shut off if you leave desk for a period of time
29 Removing Physical Files from Office How can you secure the information outside of office? Will others be able to view the materials? Do not leave in car or otherwise unattended Immediately report loss of a file Working Remotely from Home Is your home computer password protected? Does your home computer have virus protection? The same issues you have at work would apply at home when you are working remotely Home encryption capability?
30 Thoroughly document the investigation of potential breaches Make sure that breach notification is provided timely and includes all of the required elements Both to the resident and to OCR Internal risk assessments/audits and followup training are key to HIPAA compliance
31 David C. Marshall, Esq. Latsha Davis & McKenna, P.C Bent Creek Blvd., Suite 140 Mechanicsburg, PA Phone (717)
HIPAA-HITECH: Privacy & Security Updates for 2015
South Atlantic Regional Annual Conference Orlando, FL February 6, 2015 1 HIPAA-HITECH: Privacy & Security Updates for 2015 Darrell W. Contreras, Esq., LHRM Gregory V. Kerr, CHPC, CHC Agenda 2 OCR On-Site
More informationInside the OCR Investigation/Audit Process 2018 PBI HEALTH LAW INSTITUTE TUESDAY, MARCH 13, 2017 GREGORY M. FLISZAR, J.D., PH.D.
Inside the OCR Investigation/Audit Process 2018 PBI HEALTH LAW INSTITUTE TUESDAY, MARCH 13, 2017 GREGORY M. FLISZAR, J.D., PH.D. HIPAA GENERAL RULE PHI may not be disclosed without patient authorization
More informationHIPAA How to Comply with Limited Time & Resources. Jonathan Pantenburg, MHA, Senior Consultant August 17, 2017
HIPAA How to Comply with Limited Time & Resources Jonathan Pantenburg, MHA, Senior Consultant JPantenburg@Stroudwater.com August 17, 2017 Stroudwater Associates is a leading national healthcare consulting
More informationUpdate on HIPAA Administration and Enforcement. Marissa Gordon-Nguyen, JD, MPH October 7, 2016
Update on HIPAA Administration and Enforcement Marissa Gordon-Nguyen, JD, MPH October 7, 2016 Updates Policy Development Breaches Enforcement Audit 2 POLICY DEVELOPMENT RECENTLY PUBLISHED: RIGHT OF ACCESS,
More informationHIPAA in 2017: Hot Topics You Can t Ignore. Danika Brinda, PhD, RHIA, CHPS, HCISPP March 16, 2017
HIPAA in 2017: Hot Topics You Can t Ignore Danika Brinda, PhD, RHIA, CHPS, HCISPP March 16, 2017 Breach Notification State Law Privacy Rule Authorizations Polices and Procedures The Truth Is Have created
More informationHow Secure Do You Feel About Your HIPAA Compliance Plan? Daniel F. Shay, Esq.
How Secure Do You Feel About Your HIPAA Compliance Plan? Daniel F. Shay, Esq. Word Count: 2,268 Physician practices have lived with the reality of HIPAA for over twenty years. In that time, it has likely
More informationSecurity and Privacy Breach Notification
Security and Privacy Breach Notification Version Approval Date Owner 1.1 May 17, 2017 Privacy Officer 1. Purpose To ensure that the HealthShare Exchange of Southeastern Pennsylvania, Inc. (HSX) maintains
More informationQUALITY HIPAA December 23, 2013
December 23, 2013 Page 1 of 5 Breach, HIPAA and Protected Health Information This week, we look at the rules governing HIPAA, the HITECH Act and HIPAA Omnibus Rule. Unsecured PHI means Protected Health
More informationThe ABCs of HIPAA Security
The ABCs of HIPAA Security Daniel F. Shay, Esq 24 th Annual Health Law Institute Pennsylvania Bar Institute March 13, 2018 c. 2018 Alice G. Gosfield and Associates PC 1 Daniel F. Shay, Esq. Alice G. Gosfield
More informationUniversity of Wisconsin-Madison Policy and Procedure
Page 1 of 10 I. Policy The Health Information Technology for Economic and Clinical Health Act regulations ( HITECH ) amended the Health Information Portability and Accountability Act ( HIPAA ) to establish
More informationHIPAA Privacy & Security Training. Privacy and Security of Protected Health Information
HIPAA Privacy & Security Training Privacy and Security of Protected Health Information Course Competencies: This training module addresses the essential elements of maintaining the HIPAA Privacy and Security
More informationHIPAA & Privacy Compliance Update
HIPAA & Privacy Compliance Update Vermont Medical Society FREE Wednesday Webinar Series March 15, 2017 Anne Cramer and Shireen Hart Primmer Piper Eggleston & Cramer PC acramer@primmer.com shart@primmer.com
More informationInto the Breach: Breach Notification Requirements in the Wake of the HIPAA Omnibus Rule
Into the Breach: Breach Notification Requirements in the Wake of the HIPAA Omnibus Rule The Twenty-Second National HIPAA Summit Healthcare Privacy and Security After HITECH and Health Reform Rebecca Williams,
More informationDATA PRIVACY & SECURITY THE CHANGING HIPAA CLIMATE
DATA PRIVACY & SECURITY THE CHANGING HIPAA CLIMATE Melodi (Mel) M. Gates mgates@pattonboggs.com (303) 894-6111 October 25, 2013 THE CHANGING PRIVACY CLIMATE z HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY
More informationBreach Notification Remember State Law
Breach Notification HITECH: First federal law mandating breach notification for health care industry Applies to covered entities, business associates, PHR vendors, and PHR service providers FTC regulates
More informationFederal Breach Notification Decision Tree and Tools
Federal Breach Notification and Tools Disclaimer This document is copyright 2009 by the Long Term Care Consortium (LTCC). These materials may be reproduced and used only by long-term health care providers
More informationUpdate on Administration and Enforcement of the HIPAA Privacy, Security, and Breach Notification Rules
Update on Administration and Enforcement of the HIPAA Privacy, Security, and Breach Notification Rules Marissa Gordon-Nguyen Office for Civil Rights (OCR) U.S. Department of Health and Human Services June
More informationHIPAA Federal Security Rule H I P A A
H I P A A HIPAA Federal Security Rule nsurance ortability ccountability ct of 1996 HIPAA Introduction - What is HIPAA? HIPAA = The Health Insurance Portability and Accountability Act A Federal Law Created
More informationHIPAA Audit Don t just bet the odds Good luck is a residue of preparation. Jack Youngblood
HIPAA Audit Don t just bet the odds Good luck is a residue of preparation. Jack Youngblood Braun Tacon Process Architect / Auditor Owner: www.majorincidenthandling.com Winning Lotto.1 in 175 Million Attacked
More informationAgenda. Hungry, Hungry HIPAA: Security, Enforcement, Audits, & More. Health Law Institute
Health Law Institute Hungry, Hungry HIPAA: Security, Enforcement, Audits, & More Brooke Bennett Aziere October 18, 2017 Agenda Enforcement Trends Phase 2 HIPAA Audits Upcoming Initiatives 1 Enforcement
More informationA Panel Discussion. Nancy Davis
A Panel Discussion 1 Nancy Davis Director of Compliance & Safety, Door County Medical Center Cathy Hansen Director, Health Information Services & Privacy Officer, St. Croix Regional Medical Center Rhonda
More informationHIPAA Security Manual
2010 HIPAA Security Manual Revised with HITECH ACT Amendments Authored by J. Kevin West, Esq. 2010 HALL, FARLEY, OBERRECHT & BLANTON, P.A. DISCLAIMER This Manual is designed to set forth general policies
More informationDecrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use
Click to edit Master title style Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Andy Petrovich, MHSA, MPH M-CEITA / Altarum Institute October 1, 2014 10/1/2014 1 1 Who is
More informationNeil Peters-Michaud, CHAMP Cascade Asset Management ITAM Awareness Month December 2016
Breach New Heights The role of ITAM in preventing a data breach Neil Peters-Michaud, CHAMP Cascade Asset Management ITAM Awareness Month December 2016 Agenda Why Breaches Matter to the ITAM group The cost
More informationHow to Respond to a HIPAA Breach. Tuesday, Oct. 25, 2016
How to Respond to a HIPAA Breach Tuesday, Oct. 25, 2016 This Webinar is Brought to You By. About HealthInsight and Mountain-Pacific Quality Health HealthInsight and Mountain-Pacific Quality Health are
More informationEnforcement of Health Information Privacy & Security Standards Federal Enforcement Through Recent Cases and Tools to Measure Regulatory Compliance
Enforcement of Health Information Privacy & Security Standards Federal Enforcement Through Recent Cases and Tools to Measure Regulatory Compliance Iliana Peters, JD, LLM, HHS Office for Civil Rights Kevin
More informationWHITE PAPER. HIPAA Breaches Continue to Rise: Avoid Becoming a Casualty
WHITE PAPER HIPAA Breaches Continue to Rise: Avoid Becoming a Casualty WHITE PAPER HIPAA Breaches Continue to Rise: Avoid Becoming a Casualty By Jill Brooks, MD, CHCO and Katelyn Byrne, BSN, RN Data Breaches
More informationHIPAA FOR BROKERS. revised 10/17
HIPAA FOR BROKERS revised 10/17 COURSE PURPOSE The purpose of this information is to help ensure that all Optima Health Brokers are prepared to protect the privacy and security of our members health information.
More informationPolicy and Procedure: SDM Guidance for HIPAA Business Associates
Policy and Procedure: SDM Guidance for HIPAA Business (Adapted from UPMC s Guidance for Business at http://www.upmc.com/aboutupmc/supplychainmanagement/documents/guidanceforbusinessassociates.pdf) Effective:
More informationPrivacy & Information Security Protocol: Breach Notification & Mitigation
The VUMC Privacy Office coordinates compliance with the required notification steps and prepares the necessary notification and reporting documents. The business unit from which the breach occurred covers
More informationThe Relationship Between HIPAA Compliance and Business Associates
The Relationship Between HIPAA Compliance and Business Associates 1 HHS Wall of Shame 20% Involved Business Associates Based on HHS Breach Portal: Breaches Affecting 500 or More Individuals, Type of Breach
More informationDON T GET STUNG BY A BREACH! WHAT'S NEW IN HIPAA PRIVACY AND SECURITY
DON T GET STUNG BY A BREACH! WHAT'S NEW IN HIPAA PRIVACY AND SECURITY Practice Areas: Healthcare Labor and Employment JASON YUNGTUM jyungtum@clinewilliams.com (402) 397 1700 Practice Areas: Healthcare
More informationUpdate on Administration and Enforcement of the HIPAA Privacy, Security, and Breach Notification Rules
Update on Administration and Enforcement of the HIPAA Privacy, Security, and Breach Notification Rules Wandah Hardy, RN BSN, MPA Equal Opportunity Specialist/Investigator Office for Civil Rights (OCR)
More informationLessons Learned from Recent HIPAA Enforcement Actions, Breaches, and Pilot Audits
Lessons Learned from Recent HIPAA Enforcement Actions, Breaches, and Pilot Audits Iliana L. Peters, J.D., LL.M. Senior Advisor for HIPAA Compliance and Enforcement OCR RULEMAKING UPDATE What s s Done?
More informationPRIVACY-SECURITY INCIDENT REPORT
SECTION I GENERAL INFORMATION Name of Staff Member Reporting Incident PRIVACY-SECURITY INCIDENT REPORT Telephone Number Email Address Division/Office/Facility Unit/Section Supervisor SECTION II PRIVACY
More informationCyber Security Issues
RHC Summit 6/9/2017 Cyber Security Issues Dennis E. Leber CISO CHFS Why is it Important? Required by Law Good Business Strategy Right Thing to Do Why is it Important? According to Bitglass' 2017 Healthcare
More informationHIPAA ( ) HIPAA 2017 Compliancy Group, LLC
855 85 HIPAA (855-854-4722) www.compliancygroup.com 1 Started in 2005 by HIPAA auditors & Compliance experts Market need for a total end client solution Created The Guard: cloud-based solution Compliance
More informationCore Elements of HIPAA The Privacy Rule establishes individuals privacy rights and addresses the use and disclosure of protected health information ( PHI ) by covered entities and business associates The
More informationCyber Attacks and Data Breaches: A Legal and Business Survival Guide
Cyber Attacks and Data Breaches: A Legal and Business Survival Guide August 21, 2012 Max Bodoin, Vince Farhat, Shannon Salimone Copyright 2012 Holland & Knight LLP. All Rights Reserved What this Program
More informationHIPAA Privacy, Security and Breach Notification
HIPAA Privacy, Security and Breach Notification HCCA East Central Regional Annual Conference October 2013 Disclaimer The information contained in this document is provided by KPMG LLP for general guidance
More informationAudits Accounting of disclosures
Once more unto the breach Mastering HIPAA s data breach notification requirements September 20, 2011 Presented by: Kathy Kenady Senior Loss Prevention Representative Medical Insurance Exchange of California
More informationThe HIPAA Omnibus Rule
The HIPAA Omnibus Rule What You Should Know and Do as Enforcement Begins Rebecca Fayed, Associate General Counsel and Privacy Officer Eric Banks, Information Security Officer 3 Biographies Rebecca C. Fayed
More informationPutting It All Together:
Putting It All Together: The Interplay of Privacy & Security Regina Verde, MS, MBA, CHC Chief Corporate Compliance & Privacy Officer University of Virginia Health System 2017 ISPRO Conference October 24,
More information3/24/2014. Agenda & Objectives. HIPAA Security Rule. Compliance Institute. Background and Regulatory Overlay. OCR Statistics/
Compliance Institute Session 501: Implementing a System-Wide Access Monitoring Program Brian D. Annulis Meade, Roach & Annulis, LLP Aegis Compliance & Ethics Center, LLP 4147 N. Ravenswood Avenue Suite
More informationHIPAA Faux Pas. Lauren Gluck Physician s Computer Company User s Conference 2016
HIPAA Faux Pas Lauren Gluck Physician s Computer Company User s Conference 2016 Goals of this course Overview of HIPAA and Protected Health Information Define HIPAA s Minimum Necessary Rule Properly de-identifying
More informationWhat s New with HIPAA? Policy and Enforcement Update
What s New with HIPAA? Policy and Enforcement Update HHS Office for Civil Rights New Initiatives Precision Medicine Initiative (PMI), including Access Guidance Cybersecurity Developer portal NICS Final
More informationENCRYPTION: ADDRESSABLE OR A DE FACTO REQUIREMENT?
ENCRYPTION: ADDRESSABLE OR A DE FACTO REQUIREMENT? Jonathan Carroll, MBA, CISSP AVP Enterprise IT Operations Information Security Officer University of Connecticut Why Are We Talking About This? Data breaches
More informationHospital Council of Western Pennsylvania. June 21, 2012
Updates on OCR s HIPAA Enforcement and Regulations Hospital Council of Western Pennsylvania June 21, 2012 Topics HIPAA Privacy and Security Rule Enforcement HITECH Breach Notification OCR Audit Program
More informationHIPAA and HIPAA Compliance with PHI/PII in Research
HIPAA and HIPAA Compliance with PHI/PII in Research HIPAA Compliance Federal Regulations-Enforced by Office of Civil Rights State Regulations-Texas Administrative Codes Institutional Policies-UTHSA HOPs/IRB
More informationHIPAA. Developed by The University of Texas at Dallas Callier Center for Communication Disorders
HIPAA Developed by The University of Texas at Dallas Callier Center for Communication Disorders Purpose of this training Everyone with access to Protected Health Information (PHI) must comply with HIPAA
More informationCERT Symposium: Cyber Security Incident Management for Health Information Exchanges
Pennsylvania ehealth Partnership Authority Pennsylvania s Journey for Health Information Exchange CERT Symposium: Cyber Security Incident Management for Health Information Exchanges June 26, 2013 Pittsburgh,
More informationLesson Three: False Claims Act and Health Insurance Portability and Accountability Act (HIPAA)
Lesson Three: False Claims Act and Health Insurance Portability and Accountability Act (HIPAA) Introduction: Welcome to Honesty and Confidentiality Lesson Three: The False Claims Act is an important part
More informationHIPAA Compliance Checklist
HIPAA Compliance Checklist Hospitals, clinics, and any other health care providers that manage private health information today must adhere to strict policies for ensuring that data is secure at all times.
More informationHIPAA Tips and Advice for Your. Medical Practice
HIPAA Tips and Advice for Your Ericka L. Adler Medical Practice Rachel V. Rose WHY Header HIPAA PATIENT and Medical PORTALS? Practices HIPAA Basics Who is a covered entity? What is PHI? When can you disclose
More informationHIPAA Privacy and Security. Rochelle Steimel, HIPAA Privacy Official Judy Smith, Staff Development January 2012
HIPAA Privacy and Security Rochelle Steimel, HIPAA Privacy Official Judy Smith, Staff Development January 2012 Goals and Objectives Course Goal: Can serve as annual HIPAA training for physician practice
More informationORA HIPAA Security. All Affiliate Research Policy Subject: HIPAA Security File Under: For Researchers
All Affiliate Research Policy Subject: HIPAA File Under: For Researchers ORA HIPAA Issuing Department: Office of Research Administration Original Policy Date Page 1 of 5 Approved by: May 9,2005 Revision
More informationHIPAA Security & Privacy
HIPAA Security & Privacy New Omnibus Regulations Prepared by Keith Weiner for New York State HIMSS Omnibus Rule Released on January 25, 2013, the final 563 page Omnibus Rule is the largest sweeping change
More informationHIPAA Privacy & Security Training. HIPAA The Health Insurance Portability and Accountability Act of 1996
HIPAA Privacy & Security Training HIPAA The Health Insurance Portability and Accountability Act of 1996 AMTA confidentiality requirements AMTA Professional Competencies 20. Documentation 20.7 Demonstrate
More informationElements of a Swift (and Effective) Response to a HIPAA Security Breach
Elements of a Swift (and Effective) Response to a HIPAA Security Breach Susan E. Ziel, RN BSN MPH JD Krieg DeVault LLP Past President, The American Association of Nurse Attorneys Disclaimer The information
More informationHIPAA 101: What All Doctors NEED To Know
HIPAA 101: What All Doctors NEED To Know 1 HIPAA Basics HIPAA: Health Insurance and Portability Accountability Act of 1996 Purpose: to protect confidential information through improved security and privacy
More informationSecurity Rule for IT Staffs. J. T. Ash University of Hawaii System HIPAA Compliance Officer
Security Rule for IT Staffs J. T. Ash University of Hawaii System HIPAA Compliance Officer jtash@hawaii.edu hipaa@hawaii.edu Disclaimer HIPAA is a TEAM SPORT and everyone has a role in protecting protected
More informationTerms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in the HIPAA Privacy Rule.
Medical Privacy Version 2018.03.26 Business Associate Agreement This Business Associate Agreement (the Agreement ) shall apply to the extent that the Lux Scientiae HIPAA Customer signee is a Covered Entity
More informationPrivacy Breach Policy
1. PURPOSE 1.1 The purpose of this policy is to guide NB-IRDT employees and approved users on how to proceed in the event of a privacy breach, and to demonstrate to stakeholders that a systematic procedure
More informationSample BYOD Policy. Copyright 2015, PWW Media, Inc. All Rights Reserved. Duplication, Reproduction or Distribution by Any Means Prohibited.
Sample BYOD Policy Copyright 2015, PWW Media, Inc. All Rights Reserved. Duplication, Reproduction or Distribution by Any Means Prohibited. SAMPLE BRING YOUR OWN DEVICE POLICY TERMS OF USE This Sample Bring
More informationData Compromise Notice Procedure Summary and Guide
Data Compromise Notice Procedure Summary and Guide Various federal and state laws require notification of the breach of security or compromise of personally identifiable data. No single federal law or
More informationHIPAA Privacy, Security Lessons from 2016 and What's Next in 2017
HIPAA Privacy, Security Lessons from 2016 and What's Next in 2017 Session 9, February 20, 2017 Deven McGraw, Deputy Director, Health Information Privacy HHS Office for Civil Rights 1 Speaker Introduction
More informationOverview of Presentation
A HIPAA Security Incident and Investigation. It Can Happen to You. Sandra a L. Sessoms, RN, CPHQ, CHC Interim Vice President, System Compliance West Penn Allegheny Health System Robert R. Michalski, CHC
More informationHIPAA Compliance Officer Training By HITECH Compliance Associates. Building a Culture of Compliance
HIPAA Compliance Officer Training By HITECH Compliance Associates Building a Culture of Compliance Your Instructor Is Michael McCoy Nationally Recognized HIPAA Expert » Nothing contained herein should
More informationHIPAA Compliance: What it is, what it means, and what to do about it. Adam Carlson, Security Solutions Consultant Intapp
HIPAA Compliance: What it is, what it means, and what to do about it. Adam Carlson, Security Solutions Consultant Intapp Agenda Introductions HIPAA Background and History Overview of HIPAA Requirements
More informationHIPAA Security and Privacy Policies & Procedures
Component of HIPAA Security Policy and Procedures Templates (Updated for HITECH) Total Cost: $495 Our HIPAA Security policy and procedures template suite have 71 policies and will save you at least 400
More informationHIPAA COMPLIANCE AND DATA PROTECTION Page 1
HIPAA COMPLIANCE AND DATA PROTECTION info@resultstechnology.com 877.435.8877 Page 1 CONTENTS Introduction..... 3 The HIPAA Security Rule... 4 The HIPAA Omnibus Rule... 6 HIPAA Compliance and RESULTS Cloud
More informationCompliance A primer. Surveys indicate that 80% of the spend on IT security technology is driven by the need to comply with regulatory legislation.
Compliance A primer Surveys indicate that 80% of the spend on IT security technology is driven by the need to comply with regulatory legislation. The growth in the sharing of sensitive data combined with
More informationHIPAA UPDATE. Michael L. Brody, DPM
HIPAA UPDATE Michael L. Brody, DPM Objectives: How to respond to a patient s request for a copy of their records. Understand your responsibilities after you send information out to another doctor, hospital
More informationIncident Response: Are You Ready?
Incident Response: Are You Ready? Chris Apgar, CISSP Apgar & Associates, LLC 2014 Security Incident vs. Breach Overview Security Incident Planning and Your Team Final Breach Notification Rule a refresher
More information(c) Apgar & Associates, LLC
Incident Response: Are You Ready? Chris Apgar, CISSP Apgar & Associates, LLC 2014 Security Incident vs. Breach Overview Security Incident Planning and Your Team Final Breach Notification Rule a refresher
More informationRed Flags/Identity Theft Prevention Policy: Purpose
Red Flags/Identity Theft Prevention Policy: 200.3 Purpose Employees and students depend on Morehouse College ( Morehouse ) to properly protect their personal non-public information, which is gathered and
More informationHIPAA Security and Research VALERIE GOLDEN, HIPAA SECURITY OFFICER
HIPAA Security and Research VALERIE GOLDEN, HIPAA SECURITY OFFICER Researchers Must Ensure... Electronic Protected Health Information (ephi) in their possession or under their control is secured from unauthorized
More informationThe simplified guide to. HIPAA compliance
The simplified guide to HIPAA compliance Introduction HIPAA, the Health Insurance Portability and Accountability Act, sets the legal requirements for protecting sensitive patient data. It s also an act
More informationAll Aboard the HIPAA Omnibus An Auditor s Perspective
All Aboard the HIPAA Omnibus An Auditor s Perspective Rick Dakin CEO & Chief Security Strategist February 20, 2013 1 Agenda Healthcare Security Regulations A Look Back What is the final Omnibus Rule? Changes
More informationBeam Technologies Inc. Privacy Policy
Beam Technologies Inc. Privacy Policy Introduction Beam Technologies Inc., Beam Dental Insurance Services LLC, Beam Insurance Administrators LLC, Beam Perks LLC, and Beam Insurance Services LLC, (collectively,
More informationEmployee Security Awareness Training Program
Employee Security Awareness Training Program Date: September 15, 2015 Version: 2015 1. Scope This Employee Security Awareness Training Program is designed to educate any InComm employee, independent contractor,
More informationHIPAA For Assisted Living WALA iii
Table of Contents The Wisconsin Assisted Living Association... ix Mission... ix Vision... ix Values... ix Acknowledgments... ix Who Should Use This Manual... x How to Use This Manual... x Updates and Forms...
More informationHIPAA/HITECH Act Update HCCA South Central Regional Annual Conference December 2, Looking Back at 2011
HIPAA/HITECH Act Update HCCA South Central Regional Annual Conference December 2, 2012 Phyllis F. Granade The Granade Law Firm Atlanta, GA (678) 705 2507 pgranade@granadelaw.com www.granadelaw.com Looking
More informationHIPAA Privacy, Security and Breach Notification 2017
HIPAA Privacy, Security and Breach Notification 2017 An Eagle Associates Presentation Eagle Associates, Inc. www.eagleassociates.net info@eagleassociates.net P.O. Box 1356 Ann Arbor, MI 48106 800-777-2337
More informationNot Just Another Day of HIPAA
Not Just Another Day of HIPAA Presented by: Patti Klingel, PhD, CPHQ, CRM, CHC Director of Corporate Compliance & Organizational Ethics United Church Homes, Inc. Disclosure I have no vested interest in
More informationNMHC HIPAA Security Training Version
NMHC HIPAA Security Training 2017 Version HIPAA Data Security HIPAA Data Security is intended to provide the technical controls to ensure electronic Protected Health Information (PHI) is kept secure and
More informationPresented by: Jason C. Gavejian Morristown Office
Presented by: Jason C. Gavejian Morristown Office jason.gavejian@jacksonlewis.com 973.538.6890 } Unauthorized use of, or access to, records or data containing personal information Personal Information
More informationView the Replay on YouTube
View the Replay on YouTube HIPAA Omnibus Rule: Education & Practical Application for Breach Notification FairWarning Executive Webinar Series February 19, 2013 Agenda Breach Notification changes under
More informationHIPAA/HITECH Privacy & Security Checklist Assessment HIPAA PRIVACY RULE
164.502 Develop "minimum necessary" policies for: HIPAA PRIVACY RULE 164.514 - Uses 15 Exempts disclosure for the purpose of treatment from the minimum necessary standard. Page references for - Routine
More informationMobile Device Policy. Augusta University Medical Center Policy Library. Policy Owner: Information Technology Support and Services
Augusta University Medical Center Policy Library Mobile Device Policy Policy Owner: Information Technology Support and Services POLICY STATEMENT Augusta University Medical Center (AUMC) discourages the
More informationData Backup and Contingency Planning Procedure
HIPAA Security Procedure HIPAA made Easy Data Backup and Contingency Planning Procedure Please fill in date implemented and updates for your facility: Goal: This document will serve as our back-up storage
More informationHIPAA Privacy, Security and Breach Notification 2018
HIPAA Privacy, Security and Breach Notification 2018 An Eagle Associates Presentation Eagle Associates, Inc. www.eagleassociates.net info@eagleassociates.net P.O. Box 1356 Ann Arbor, MI 48106 800-777-2337
More informationCompliance & HIPAA Annual Education
Compliance & HIPAA Annual Education 1 The purpose of this education is to UPDATE The purpose and of this education REFRESH is to UPDATE your and REFRESH understanding understanding of: of: Aultman s Compliance
More informationCYBERSECURITY. Recent OCR Actions & Cyber Awareness Newsletters. Claire C. Rosston
CYBERSECURITY Recent OCR Actions & Cyber Awareness Newsletters Claire C. Rosston DISCLAIMER This presentation is similar to any other legal education materials designed to provide general information on
More informationInformation Technology Standards
Information Technology Standards IT Standard Issued: 9/16/2009 Supersedes: New Standard Mobile Device Security Responsible Executive: HSC CIO Responsible Office: HSC IT Contact: For questions about this
More informationWASHINGTON UNIVERSITY HIPAA Privacy Policy # 7. Appropriate Methods of Communicating Protected Health Information
WASHINGTON UNIVERSITY HIPAA Privacy Policy # 7 Appropriate Methods of Communicating Protected Health Information Statement of Policy Washington University and its member organizations (collectively, Washington
More informationHIPAA & HITECH Training 2018
HIPAA & HITECH Training 2018 Welcome 2018 Compliance Training Section 1: HIPAA Privacy Section 2: HIPAA Security Section 3: HITECH Section 4: Reporting a Breach Section 5: Disciplinary Actions Section
More informationBoerner Consulting, LLC Reinhart Boerner Van Deuren s.c.
Catherine M. Boerner, Boerner Consulting LLC Heather Fields, 1 Discuss any aggregate results of the desk audits Explore the Sample(s) Requested and Inquire of Management requests for the full on-site audits
More informationWhen the Other Brother Steps Up: State Privacy Enforcement Actions
When the Other Brother Steps Up: State Privacy Enforcement Actions Healthcare Enforcement Compliance Conference November 6, 2018 Washington, DC Blaine Kerr, CISA, CHPC Chief Privacy Officer Jackson Health
More informationSecuring IT Infrastructure Improve information exchange and comply with HIPAA, HITECH, and ACA mandates
Securing IT Infrastructure Improve information exchange and comply with HIPAA, HITECH, and ACA mandates Ruby Raley, Director Healthcare Solutions Axway Agenda Topics: Using risk assessments to improve
More information