The U.S. Department of Health and Human Services (HHS), through the Office for Civil Rights (OCR), announced the formation of a new Enforcement Division, Policy Division, and Strategic Planning Division.
The newly established Strategic Planning Division will coordinate the OCR’s authorities to protect civil rights and health information privacy as well as expand data analytics and coordinate data collection across the HHS leadership.
“As a trusted advisor and leader of the newly established division, Luis Perez will direct the standalone Enforcement Division that will provide vital integration between our regional offices and headquarters staff to swiftly investigate and determine appropriate steps for all complaints we receive,” said Director Fontes Rainer. “This structure will enable OCR staff to leverage its deep expertise and skills to ensure that we are protecting individuals under the range of federal laws that we are tasked with enforcing.”
The OCR will rename the Health Information Privacy Division (HIP) to the Health Information Privacy, Data, and Cybersecurity Division (HIPDC).
The OCR’s caseload has multiplied in recent years, increasing to over 51,000 complaints in 2022.
By the time you finish reading this blog you could be next!
Would the Office for Civil Rights open an investigation for:
Missing your Notice of Privacy Practices on your website, or missing a patient signature for it, probably not.
For an incorrect patient sign-in sheet, probably not.
Lack of no-surprise billing notice on your website, probably not.
Would the Office for Civil Rights open an investigation for:
Privacy complaint from a patient, YES.
Information blocking complaint from a patient, YES.
Report from a disgruntled employee, YES.
HOWEVER, one patient or disgruntled employee’s complaint opens the door for the OCR. Then, they will review ALL your HIPAA compliance efforts. Including the items listed above that they would not start an investigation with. With this new enforcement division, this has crossed a new threshold.
Is your practice at risk of being one of the three to be investigated tomorrow? The best way to avoid a HIPAA desk audit is through proper HIPAA documentation.
Most investigations can be avoided by supplying the OCR with proper documentation! How well do you trust yours?
If you are using our HIPAA Keeper™ 7-step system, you are well ahead of many other practices with HIPAA documentation. If you are not using our system, Click here to find out more how our online HIPAA Keeper™ can help your organization with HIPAA Compliance.
Or to schedule a demo click the contact us tab and scroll down.
“Simplifying HIPAA through Automation, Education, and Support”
With so many data breaches in the news many medical practitioners are asking if they can be sued over HIPAA violations or from a data breach.
HIPAA rules state there is no private right of action, therefore, a patient cannot sue for a HIPAA violation. With that said, it is possible if there were privacy violations under state law, legal action may be taken. All states have their own set of privacy laws that encompasses more than just the healthcare sector. State privacy laws vary from state to state and define what is considered private information. HIPAA and state laws require covered entities to secure protected health information (PHI) with administrative, physical, and technical safeguards. Business associates and subcontractors are required to do the same.
If a patient wants to file a lawsuit, the patient must be able to prove negligence and damage caused harm by the violation or data breach. The Omnibus Rule removed the harm threshold when it came to covered entities reporting data breaches, but a patient has the right to claim harm. On another note, if a patient joins a class action lawsuit, it may make a stronger case. However, many class action lawsuits are filed based on the exposure to future harm. Without evidence of harm this may reduce the case. This can be a costly endeavor and patients should consider this and review what they hope to gain before taking legal action. Keep in mind, this is not a quick lawsuit. In the end, there is no guarantee of any monetary gain for the patient.
Many times, the practice can discuss the issues with the patient and avoid legal action altogether. It is recommended that if a practice has a disgruntled patient, the HIPAA privacy officer should talk to the patient if given the opportunity. Sometimes, an upset patient merely wants to be heard. Depending on the circumstances, the practice may be required to report the incident to the Department of Health and Human Services Office for Civil Rights (OCR).
If a patient feels as though their protected health information has been violated, they do have the right to file a complaint with the OCR. The complaint from the patient must be filed within 180 days of the incident. In some cases, an extension may be permitted. The complaint is reviewed to determine if it is justifiable. If it is, then the OCR will contact the practice and try to resolve the issue in the most suitable manner. This may include technical assistance, a resolution agreement, and/or ongoing compliance documentation. The average investigation timeline for a data breach takes 1½ – 2 years. Of course, for more complex breaches, it may take even longer. The outcome of the investigation will depend on the severity and nature of the violation, if this was a repeated offense, and the number of patients affected. Depending on the documentation of the incident and how it was handled, a practice may be able to avoid a desk audit. Remember, if it’s not documented, it does not exist. The patient may also file a complaint with the State Attorney General. Some complaints are referred to the Department of Justice (DOJ) if the investigation results in criminal violations. I hope this helps you to understand how important it is to keep patient data secure, and the documentation that demonstrates your efforts. If you have any questions on data security, how to handle a patient complaint, or how to handle a security incident, we are here to help.
To find out more about how our online HIPAA Keeper™ can help your organization with HIPAA Compliance click here:
Medical professionals have had a rough year and a half. This has been trying times for so many and we have had to learn to adapt to new ways of running practices. I was hoping to be able to share some good news during this time of thankfulness and joyous season, but the Office for Civil Rights do not take breaks… This is not meant to be disrespectful but to inform you that when a patient files a complaint, the OCR takes that seriously and will open an investigation. So, during this holiday season, please stay vigilant to patient requests. Be sure to have the patient make the request in writing and no sticky notes allowed! DOCUMENTATION is your friend, not your enemy. Make sure this task is completed in a timely manner. These forms are included in your HIPAA compliance program if you do not have one already in use.
The Office for Civil Rights is VERY interested in how timely you answer a patient’s request to access their medical records. This is known as “Right of Access”. A patient has the “right” to request a copy of their medical records and this should be provided within 30 days, or if additional time is needed, a 30-day extension may be permitted if the patient has been notified of the reason and the delay with a date that the records will be made available.
In September the OCR announced the twentieth settlement for right of access violations. Earlier this month, they announced five more.
The Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) announced the resolution of five investigations in its Health Insurance Portability and Accountability Act (HIPAA) Right of Access Initiative, bringing the total number of these enforcement actions to twenty-five since the initiative began. OCR created this initiative to support individuals’ right to timely access their health records at a reasonable cost under the HIPAA Privacy Rule.
HIPAA gives people the right to see and get copies of their health information from their healthcare providers and health plans. After receiving a request, an entity that is regulated by HIPAA has, absent an extension, 30 days to provide an individual or their representative with their records in a timely manner.
“Timely access to your health records is a powerful tool in staying healthy, patient privacy and it is your right under law,” said OCR Director Lisa J. Pino. “OCR will continue its enforcement actions by holding covered entities responsible for their HIPAA compliance and pursue civil money penalties for violations that are not addressed.”
OCR has taken the following enforcement actions that underscore the importance and necessity of compliance with the HIPAA Right of Access:
Advanced Spine & Pain Management (ASPM), which provides management and treatment of chronic pain services in Cincinnati and Springboro, Ohio, has agreed to take corrective actions that include two years of monitoring, and has paid OCR $32,150 to settle a potential violation of the HIPAA Privacy Rule’s right of access standard.
Denver Retina Center, a provider of ophthalmological services in Denver, CO, has agreed to take corrective actions that includes one year of monitoring and has paid OCR $30,000 to settle a potential violation of the HIPAA Privacy Rule’s right of access standard.
Dr. Robert Glaser, a cardiovascular disease and internal medicine doctor in New Hyde Park, NY, did not cooperate with OCR’s investigation or respond to OCR’s data requests after failing to provide a patient with a copy of their medical record. Dr. Glaser waived his right to a hearing and did not contest the findings of OCR’s Notice of Proposed Determination. Accordingly, OCR closed this case by issuing a civil money penalty of $100,000.
Wake Health Medical Group, a provider of primary care and other health care services in Raleigh, NC, has agreed to take corrective actions and has paid OCR $10,000 to settle a potential violation of the HIPAA Privacy Rule’s right of access standard.
There are many other fines being assessed that can be reviewed on the HHS/OCR website. This is not meant to scare you but rather inform you what they are doing so you can stay safe and prosperous.
All of us at Aris Medical Solutions want to wish everyone a safe and wonderful holiday season. We do not take breaks either, we are here to help you!
To find out more about how our online HIPAA Keeper™ can help your organization with HIPAA Compliance click here:
Recently a cosmetic practice was fined $30,000 to settle potential HIPAA Privacy Rule violations. In the past many practices believed if they did not accept insurance payments (considered as a “transaction” under HIPAA), they were immune from the privacy rule. This may not be the case. There is a section in the rule that states “Other transactions that the Secretary may prescribe by regulation”. HIPAA compliance is a balancing act, are you willing to lose $30K of your hard-earned money to test the system?
This investigation started with a compliant from a patient that had requested their medical record and did not receive them in a timely manner. Under the HIPAA Privacy Rule, the provider must respond to a patient’s request for access no later than 30 calendar days after the request. If the covered entity is not able to act within this timeframe, the entity may have up to an additional 30 calendar days if they provide the individual (within the initial 30-day period) with a written statement for the reason of the delay and include a date when the entity will have the information available. See 45 CFR §164.524(b)(2). Unfortunately for this practice, this was not handled in a timely manner. Therefore, an investigation was launched.
Let us review how this happens.
Once a complaint is filed to the Office for Civil Rights (OCR), the OCR will determine if the complaint falls within their duties to investigate. Once an investigation has been opened, the OCR will contact the practice for their documentation surrounding the incident. Depending on the documentation that is submitted will determine if a desk audit is warranted. Therefore, documentation is SO important, you may be able to avoid a desk audit if you supply the appropriate documents.
During a desk audit more than likely, you will be asked for documentation of what preventative measures you had in place before the incident and what you have implemented to prevent this from happening again. While you are being investigated the OCR may also review your compliance in other areas. If they find discrepancies, you could be fined for those as well. HIPAA encompasses a large range of requirements. Patient privacy, patient rights, and data security to name a few. I will not go into detail during this notification since we are sharing the security rule requirements in other messages.
Each resolution agreement that is issued by the HHS/OCR outlines the deficiencies they uncover. Most of them include the lack of a risk analysis, risk management, training, business associate agreements, and policies and procedures. During this investigation, other violations were uncovered and included the social security act was named in the resolution agreement: Section 1128A of the Social Security Act (42 U.S.C. § 1320a- 7a) a.
From this, I hope you can understand the importance of HIPAA compliance. Because one simple oversight can cause this much heartache. Patient privacy, patient rights, and data security is as important as caring for your patients. We have just learned that any entity that has patient data can be investigated and fined for violations under HIPAA.
Tell your friends and colleagues to ensure everyone understands no one is immune from HIPAA if you have patient data. Fines are fierce and not worth taking a chance by thinking “it won’t happen to me”.
If you need assistance with HIPAA Training, Risk Management, or guidance with your HIPAA Compliance contact us at 877.659.2467 or complete the contact us form.
“Simplifying HIPAA through Partnership, Education, and Support”
What the Office for Civil Rights (OCR) and the Department of Health and Human Services (HHS) considers as reasonable and appropriate safeguards are always open for discretion. Every organization is different, and what may work for one, may not for another. For that reason, this information is a guideline only and should not be taken as legal advice.
Here are a few areas that should be reviewed:
§ 164.308(a)(5)(i) Security Awareness and Training has (4) implementation standards. They are labeled as “Addressable” under the HIPAA Security Rule. Do not be fooled by the term addressable, that does not mean optional. It just means you have options in implementing the standards.
The Security Awareness and Training standard means that a covered entity must implement a security training program for all employees including management. The frequency in which the training is performed is typically questionable and HIPAA requires new hires must be trained within a reasonable amount of time. We recommend HIPAA training BEFORE any person has access to PHI or ePHI since one mistake can cause a data breach. Then, HIPAA requires “periodic” training. Most organizations conduct annual HIPAA training. Although HHS does not specifically state you must conduct annual training, should you suffer a data breach and it is caused by an employee that did not have proper training, you could be fined for that violation. That is why it is so important to ensure your employees not only attend (and have documentation) HIPAA training, but must also actually understand what is required of them and how to safeguard patient data.
§ 164.308(a)(5)(ii)(A) Security Reminders – HIPAA is not just a once-a-year process. Periodic security reminder updates should be conducted throughout the year to keep HIPAA and data security in the minds of your staff. This should be documented as well.
§ 164.308(a)(5)(ii)(B) Protection from Malicious Code – Procedures must be in place to guard against, detect, and report viruses and malware. Up to date anti-virus and anti-malware software can ward off most intrusions. That is, as long your staff does not click on attachments or visit certain website where malicious code is located. Education is key. Ensuring software patches are applied when released, scanning systems on a routine basis, and utilizing firewalls are also very important. Making sure users do not introduce malicious code from downloads, DVDs, flash-drives, or other products brought from home.
§ 164.308(a)(5)(ii)(C) Log-in Monitoring – Procedures for monitoring log-in activity and reporting discrepancies. This standard states you must monitor user logins and unsuccessful attempts. Best practices are to have procedures to lock a user out after a predetermined number of failed log-in attempts. This may prevent an unauthorized user from gaining access to your system. With malware that repeatedly tries new passwords, this is highly recommended.
§ 164.308(a)(5)(ii)(D) Password Management – Procedures for creating, changing, and safeguarding passwords. All users must use their own credentials to log into systems that contain ePHI. Passwords are to be complex, never shared, secure, and changed at least every 90 days. Although HIPAA does not specifically state the 90-day rule, it is best practices unless you are utilizing a second method of authentication.
§ 164.308(a)(6)(i) Security Incident Procedures has (1) implementation standard, and this is “Required”. This means you MUST implement the standard as stated. You must have policies and procedures in place that identify security incidents, so employees understand what a security incident is, and how to respond.
§ 164.308(a)(6)(ii) Response and Reporting requires a covered entity to have policies and procedures in place to report and mitigate security incidents and determine if a data breach occurred. Then, if a data breach has occurred, the covered entity must determine how many patient records were affected. The time frame to report the breach to OCR and possibly state and local agencies differs on whether the breach is over 500 patient records or not. This should be clearly outlined in your Breach Notification Plan. During the breach notification process, state law will supersede the federal HIPAA law if the state law is more stringent. Keep in mind, all 50 states have their set of privacy laws.
We will be adding more information on other Security Standards, so watch for more posts!
If you need assistance with HIPAA Risk Management or guidance with your HIPAA Compliance contact us at 877.659.2467 or complete the contact us form.
It is hard to believe we are in 2021, but I am sure you are like the rest of us and glad to see 2020 in the rear-view mirror.
As we move into this new year, we need to look ahead and learn from what has happened in the past. Last month we informed you about many HIPAA violations that the Office for Civil Rights (OCR) had investigated. Most of these violations could have been prevented. In fact, I was talking with a colleague that owns an audit log monitoring system and he informed me that during the pandemic they saw a 90% increase in snooping into patient records of the same last name. Fortunately for his clients, this was immediately stopped, and the employee(s) were sanctioned. This made me want to remind you of a few requirements under HIPAA.
164.308(a)(1)(ii)(c) Sanction Policy – is a “required” standard under the HIPAA Security Rule. Employers are required by law to apply sanctions against employees who violate HIPAA, otherwise the employer could be fined.
164.308(a)(1)(ii)(d) Information System Activity Review – is another required standard. Which requires procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports. A security incident can be best described as the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system.
164.312(b) Audit Controls – is yet another required standard that states you must implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information (ePHI). This standard goes hand in hand with Information System Activity Review.
What does this mean to you?
First, you must understand what is considered “normal” usage within your software/hardware that contains ePHI. Then you must monitor your systems for abnormal behavior. This is a HUGE time-consuming task and unless you are monitoring every employee, 24/7 you may miss something. We highly recommend utilizing a third party to do this for you. The company we work with has interfaces with over 60 EHRs and is fully automated. If they do not have an interface, they will create one, or show you how to upload the logs in a matter of minutes instead of hours. No more looking over lengthy audit log reports. You simply receive an alert when there is abnormal activity. Best of all, this protects your patient data and your practice from fines and penalties. If you would like to learn more about this service, use the contact us page.
If you need assistance with HIPAA Risk Management or guidance with your HIPAA Compliance, contact us at 877.659.2467 or complete the contact us form.
Yesterday, the Office for Civil Rights (OCR) at the Department of Health and Human Services (DHHS) released its 2016-2017 HIPAA Audits Report. Although this seems outdated, it typically takes this long to compile the data.They reviewed selected covered entities (CE) and business associates (BA) for HIPAA compliance of the HIPAA Privacy, Security, and Breach Notification Rules.
DHHS is required by law under the HITECH Act to conduct periodic audits. The chances of a random audit are slim, but they do happen, and you must be prepared. Don’t be fooled by a slim chance of a random audit, you can be audited for many other reasons! This audit comprised of 166 covered entities and 41 business associates. The OCR publishes this report to share the overall findings.
A summary of the audit findings includes:
Most CEs met the timeliness requirements for providing breach notification to individuals.
Most CEs that maintained a website about their customer services or benefits satisfied the requirement to prominently post their Notice of Privacy Practices on their website.
Most CEs failed to provide all of the required content for a Notice of Privacy Practices.
Most CEs failed to provide all of the required content for breach notification to individuals.
Most CEs failed to properly implement the individual right of access requirements such as timely action within 30 days and charging a reasonable cost-based fee.
Most CEs and BAs failed to implement the HIPAA Security Rule requirements for risk analysis and risk management.
“The audit results confirm the wisdom of OCR’s increased enforcement focus on hacking and OCR’s Right of Access initiative,” said OCR Director Roger Severino. “We will continue our HIPAA enforcement initiatives until health care entities get serious about identifying security risks to health information in their custody and fulfilling their duty to provide patients with timely and reasonable, cost-based access to their medical records.”
During this pandemic, the Office for Civil Rights (OCR) relaxed some of the requirements for Telehealth. This has since been retracted. Make sure the service you are using is in fact HIPAA compliant and you have a business associate agreement (BAA) in place. We also encourage you and all your business associates (BA) to carry cyber liability insurance. Data breaches and mishaps are part of our everyday life it seems. Although your medical malpractice insurance may offer a token amount of coverage, it is probably not enough. Keep in mind, if you cannot determine WHICH patient’s data has been breached, you must notify all your patients. This is where is can be very costly. When selecting an agent, make sure they are well versed in this type of insurance, as we have seen some policies are not worth the paper they are written on. Read the exclusions!
Below are some HIPAA violation highlights from 2020. This is not meant to scare you, but to remind you of how important adhering to HIPAA really is. The Office for Civil Rights (OCR) enforcement actions are designed to send a message to the health care industry about the importance and necessity of compliance with the HIPAA Rules.
The OCR investigation found longstanding, systemic noncompliance with the HIPAA Security Rule including failure to conduct a risk analysis, and failures to implement information system activity review, security incident procedures, and access controls.
“The health care industry is a known target for hackers and cyberthieves. The failure to implement the security protections required by the HIPAA Rules, especially after being notified by the FBI of a potential breach, is inexcusable,” said OCR Director Roger Severino.
The OCR investigation discovered longstanding, systemic noncompliance with the HIPAA Privacy and Security Rules including failures to conduct a risk analysis, implement risk management and audit controls, maintain HIPAA policies and procedures, secure business associate agreements with multiple business associates, and provide HIPAA Privacy Rule training to workforce members.
“Hacking is the number one source of large health care data breaches. Health care providers that fail to follow the HIPAA Security Rule make their patients’ health data a tempting target for hackers,” said OCR Director Roger Severino.
The OCR investigation revealed that a former employee returned eight days after being terminated, logged into her old computer with her still-active user name and password. Additionally, OCR found that the former employee had shared her user ID and password with an intern, who continued to use these login credentials to access PHI after the employee was terminated. The investigation determined that the entity failed to conduct an enterprise-wide risk analysis, and failed to implement termination procedures, access controls such as unique user identification, and HIPAA Privacy Rule policies and procedures.
“Medical providers need to know who in their organization can access patient data at all times. When someone’s employment ends, so must their access to patient records,” said OCR Director Roger Severino.
The OCR investigation revealed that in addition to the impermissible disclosures, Aetna failed to perform periodic technical and nontechnical evaluations of operational changes affecting the security of their electronic PHI (ePHI); implement procedures to verify the identity of persons or entities seeking access to ePHI; limit PHI disclosures to the minimum necessary to accomplish the purpose of the use or disclosure; and have in place appropriate administrative, technical, and physical safeguards to protect the privacy of PHI.
“When individuals contract for health insurance, they expect plans to keep their medical information safe from public exposure. Unfortunately, Aetna’s failure to follow the HIPAA Rules resulted in three breaches in a six-month period, leading to this million-dollar settlement,” said OCR Director Roger Severino.
The OCR has settled twelve investigations for HIPAA Right of Access denials. This is not to be confused with a medical summary at the end of a patient encounter. A patient’s request for a copy of their medical record (their designated record set) either by them or from a third party must be handled in a timely manner.
“It shouldn’t take a federal investigation to secure access to patient medical records, but too often that’s what it takes when health care providers don’t take their HIPAA obligations seriously. OCR has many right of access investigations open across the country, and will continue to vigorously enforce this right to better empower patients,” said Roger Severino, OCR Director.
“No one should have to wait over a year to get copies of their medical records. HIPAA entitles patients to timely access to their records and we will continue our stepped up enforcement of the right of access until covered entities get the message,” said Roger Severino, OCR Director.
“The OCR is committed to enforcing patients’ right to access their medical records, including the right to direct electronic copies to a third party of their choice. HIPAA covered entities should review their policies and training programs to ensure they know and can fulfill all their HIPAA obligations whenever a patient seeks access to his or her records,” said Roger Severino, OCR Director.
“For too long, healthcare providers have slow-walked their duty to provide patients their medical records out of a sleepy bureaucratic inertia. We hope our shift to the imposition of corrective actions and settlements under our Right of Access Initiative will finally wake up healthcare providers to their obligations under the law,” said Roger Severino, OCR Director.
The OCR investigation determined that there was systemic noncompliance with the HIPAA Rules including a failure to encrypt ePHI on laptops after Lifespan ACE determined it was reasonable and appropriate to do so. OCR also uncovered a lack of device and media controls, and a failure to have a business associate agreement in place with the Lifespan Corporation.
“Laptops, cellphones, and other mobile devices are stolen every day, that’s the hard reality. Covered entities can best protect their patients’ data by encrypting mobile devices to thwart identity thieves,” said Roger Severino, OCR Director.
A breach report regarding the impermissible disclosure of protected health information to an unknown email account. The breach affected 1,263 patients. OCR’s investigation revealed longstanding, systemic noncompliance with the HIPAA Security Rule. Specifically, they failed to conduct any risk analyses, failed to implement any HIPAA Security Rule policies and procedures, and neglected to provide workforce members with security awareness training until 2016.
“Health care providers owe it to their patients to comply with the HIPAA Rules. When informed of potential HIPAA violations, providers owe it to their patients to quickly address problem areas to safeguard individuals’ health information,” said Roger Severino, OCR Director.
“All health care providers, large and small, need to take their HIPAA obligations seriously,” said OCR Director Roger Severino. “The failure to implement basic HIPAA requirements, such as an accurate and thorough risk analysis and risk management plan, continues to be an unacceptable and disturbing trend within the health care industry.”
HIPAA covered entities and business associates are required to conduct an accurate and thorough assessment of the risks to the ePHI it maintains. Identifying, assessing, and managing risk can be difficult, especially in organizations that have a large, complex technology footprint. Understanding one’s environment – particularly how ePHI is created and enters an organization, how ePHI flows through an organization, and how ePHI leaves an organization – is crucial to understanding the risks ePHI is exposed to throughout one’s organization. As technology changes, risk assessments must be updated and reflected in a risk management plan. Reviewing policies and procedures may also need to be updated depending on the type of changes in technology. As we get ready to close out 2020, set your schedule to review your updates and planned upgrades for 2021.
To read about enforcement and the resolution agreements, click on the link below:
The Office for Civil Rights (OCR) back in March relaxed it’s enforcement for non-compliance with regards to telemedicine. They permitted the use of audio/video communication applications such as Facetime, Google hangouts, Zoom, and Skype without risk that a provider could be issued a penalty for non-compliance. Providers were encouraged to inform their patients of potential privacy risks and do their best to engage encryption and whatever means they had available to secure the data.
Even though some states are experiencing a surge in more COVID cases, medical providers are expected to seek HIPAA qualified products and obtain a business associate agreement. Telehealth providers should now have an agreement ready that will include state law provisions and data security information. Medical providers should read this agreement carefully to ensure the data security is outlined and meets their state law breach notification guidelines. Ideally, it would be best for the vendor to sign YOUR business associate agreement if you have one that has outlined security requirements.
If a medical provider does not obtain a signed business associate from a vendor, the medical provider should terminate using the vendor. Just because a vendor doesn’t sign a BAA it does NOT release them from liability. It just means the liability falls on the medical provider for not obtaining the signed document. Furthermore, the medical provider may receive fines for non-compliance should the business associate suffer a data breach or security incident. These documents are extremely important!
Many thanks to all our healthcare workers for staying strong throughout these trying times.
If you would like more information or need a business associate agreement, contact us at 877.659.2467 or complete the contact us form.
“Simplifying HIPAA through Partnership, Education, and Support”
We all have been annoyed at one time or another when we arrive at a counter or a place of business and the person is on their cell phone and we are ignored. Of course, that is not very good customer service. When you work in healthcare, it goes to an all new level. HIPAA doesn’t restrict the use of cell phones, except how they are secured and protected. However, this is not what we are discussing here today.
We are hearing about complaints from patients accusing employees of taking pictures of their information. This particular situation the employee was accused of taking pictures of the computer screen and the patient told the doctor. This afforded the doctor the opportunity to address the situation and avoid a formal complaint to the Office for Civil Rights (OCR). We recommend employees leaving their cell phones out of sight of patients unless the phone is used for business purposes within the practice. Some organizations are even adding cell phone lockers. I can remember before we had cell phones, we actually gave out our work number to anyone who needed to get in contact with us! Now you know how old I really am! Joking aside, this is a very serious matter that could cause the OCR to open an investigation. Keep in mind, when you are being investigated by the OCR, they do not “just” investigate “that” situation. They look at your overall compliance plan. Where are your policies? What were your procedures before, during, and after the occurrence. What have you done to prevent the same situation from happening again? Plus, many more items they take into consideration when conducting an investigation.
The next area of concern with cell phones are with patients. We have long been a proponent of using privacy screens on computers. Now, even if the screen is across the room, we are pushing our clients to add the screens. Patients now have their phones out while making new appointments, they could potentially take pictures of computer screens across the room and enlarge them. Some of you may be thinking that we worry too much and all this security is driving you crazy. It only takes ONE mistake or ONE complaint to turn your life into a rollercoaster. Prevention is the best medicine!
If you would like more information, contact us at 877.659.2467 or complete the contact us form.
“Simplifying HIPAA through Partnership, Education, and Support”