If you really want to protect the privacy of those you serve, it is important to establish a culture of vigilance within your organization.
Now, if that sounds like blah-blah, think again. The culture of your organization is a real thing. It is a silent, yet potent communicator of the values reflected in your leadership. High ethical behavior at the top sets the expectations for all.
During our January podcast-and-webinar series, we discussed the importance of a Code of Conduct as a starting point for a HIPAA compliance program. Why? Because it's a great vehicle for describing ethical standards that employees are expected to meet. If expectations aren't in writing, how are they to know?
Basic elements of a Code of Conduct set forth principles of:
Importantly, the commitment should go both ways -- with leadership pledging a commitment to a healthy work environment and employees pledging good conduct. (Yes, pledges should be signed!)
Once the basic standards are set, then there is context for the details of HIPAA compliance relating to safety and security.
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Staff working on the ground sees everything; they are the ones likely to come across a problem that demands your attention. You need to have a reporting system established that the staff knows exists to ensure the issue will be communicated.
First, you must manage reporting systems for your agency. Create a process through which staff can submit reports either anonymously or by name. Have a system in place to ensure that once a potential breach has been communicated you have the tools ready to complete an investigation efficiently.
Remember! Review whistleblower reports regularly! Monitor to make sure investigations take place in a timely manner and are resolved.
Having a reporting system in place is only half the battle. You have to also make sure your staff:
Understands yourorganization's reporting system, and Does not fear retaliation for reporting.
Make the duty to report a part of your agency's culture. Promote awareness and understanding of the availability of whistleblower reporting and other resources your agency offers. Also promote your agency's non-retaliation policies. Make these policies known to staff in new-hire orientation and annual training, on your website, in staff memos and through other ways you communicate with staff.
Keep in mind! Communication is a two-way street. Creating a reporting system is meaningless if staff does not know to use it!
For more information, check out the section on Preventing Breaches on page 26 of the MyHIPAA Guide Compliance Manual. MyHIPAA Guide subscribers may access available templates for security incident reports and incident investigations under Appendix E of the Security Policies and Procedures template on Step 3 of the MyHIPAA Guide website.
A Business Associate is a person or organization, other than an employee of a covered entity, who performs functions or provides services related to creating, receiving, maintaining, or transmitting Protected Health Information (PHI) on behalf of your organization.
Remember!: With all of your business associates, you need an agreement that legally binds you (the HIPAA covered entity) and the business associate with very clear terms for managing and protecting health information emanating from you.
A written contract with your Business Associate must:
Detail the uses and disclosures of PHI the Business Associate may make
Require that the Business Associate safeguard PHI
In other words, if any one person or vendor has potential access to private health information, you need to hold them accountable to the same high standards as you are held accountable.
By now, you know that international ransomware attackers have hit health systems in the United States. While it’s up to the techs within your organization to apply security measures, it’s everyone’s job to thwart thieves by recognizing and avoiding their traps - often hidden in seemingly harmless emails.
Keep in mind that hackers are smart, and it’s their business to fool even the most conscientious employees in close proximity to patient information. That’s why it’s important to know the warning signs of ransomware.
Let’s start with some basics pertaining to email:
Of course the goal is to avoid the schemes of hackers, who typically “kidnap” information with the promise of releasing it back to its rightful owner in exchange for money. A joint study conducted by several security firms estimates that creators of one form of ransomware -- called CryptoWall 3.0 - have extracted more than $325 million from victims since January 2015.
In the event you fall victim to a ransomware scheme, you should know the tell-tale signs of being hacked so that you can seek help right away. One common scenario is that you click on a link or open an attachment and immediately realize it is suspicious. Get help, even if you’re not 100 percent sure it’s a problem.
Other indicators of a ransomware include:
If you do not need remote access to a database containing patient information, disable the service on your computer. If you do need remote access, use it only as necessary. And make sure your password is next to impossible to figure out. By now you may wonder what the odds are that you may encounter a ransomware threat. Well, a recent U.S. Government interagency report indicates that, on average, there have been 4,000 daily ransomware attacks since early 2016. That’s a 300% increase over the 1,000 daily ransomware attacks reported in 2015!
That is why everyone needs to have an eagle eye out for the crooks.
Here are just a few other things to keep in mind:
Simple safety practices on the part of all can thwart thieves so the can’t do their dirty work. That’s the goal -- and it takes a community of dedicated workers to achieve it.
Note: Information included in this post has been compiled from email alerts distributed by the U.S. Office for Civil Rights (OCR) from May 12 through May 16, in response to interational threats impacting healthcare. Reference material includes: February 2, 2016, and March 30, 2016 cyber awareness updates, and a February 2017 newsletter, all from OCR, and a Ransomware Fact Sheet from the U. S. Department of Health and Human Services.
The feds have released a new fact sheet that explains how HIPAA Rules permit disclosures of Protected Health Information (PHI) to support public health activities conducted by public health agencies, as authorized by state or federal law. The facc sheet offers examples of instances where the sharing PHI supports public health policies.
You may find the new fact sheet on the federal government's website at: https://www.healthit.gov/
If you haven't already, read the CMS memo to state survey agencies, ordering a crackdown on social media abuses. Policies aren't enough, the memo says. You also need ongoing, sustainable compliance plans.
In an unprecedented memo to state survey and credentialing agencies earlier this month, the Centers for Medicare & Medicaid Services directed state survey teams to begin enforcing federal privacy regulations to protect patients from social media abuses. The memo cites recent media reports as impetus for the crackdown.
In its memo, dated Aug. 5, 2016, CMS orders state survey teams to review nursing home policies and procedures related to social media abuses beginning in September, and continuing until all skilled nursing homes have been inspected. The memo points out that staff training alone is not enough, and that compliance must include plans for implementing daily practices that protect residents’ privacy. The memo defines “staff” as employees, consultants, contractors, volunteers and others who provide care services to residents.
Indeed, a growing number of reports are exposing horrific examples of staff members taking embarrassing photos and videos of residents, and then sharing them with friends.
ProPublica and the Washington Post have been especially out front on this issue. Here is some background to give you an idea of what is taking place:
In December 2015, reports co-published by ProPublica and the Washington Post revealed startling social media abuses within long-term care facilities. Indeed, the findings initially documented 37 incidents since 2012, exposing nursing home workers across the country for posting embarrassing photos of elderly residents on social media. In some cases, residents were partially or completely naked. At least 16 cases involved Snapchat, a social media platform where photos appear a few seconds, and then disappear.
Details of the incidents came from government reports, court cases and stories in the media.
An excerpt from one report on the ProPublica website:
“In February 2014, a nursing assistant at Prestige Post-Acute and Rehab Center in Centralia, Wash., sent a co-worker a Snapchat video of a resident sitting on a bedside portable toilet with her pants below her knees while laughing and singing.”
This February at Autumn Care Center in Newark, Ohio, a nursing assistant recorded a video of residents lying in bed as they were coached to say, ‘I’m in love with the coco,’ the lyrics of a gangster rap song (‘coco’ is slang for cocaine). Across a female resident’s chest was a banner that read, ‘Got these hoes trained.’ It was shared on Snapchat.”
In the latter case, the woman’s son told federal investigators that his mother had worked as a church secretary for 30 years, and would have been mortified.
In some cases, employees have faced criminal charges.
Meanwhile, in July, the U.S. Office for Civil Rights announced that federal audits have moved into “high gear” under the Health Information Portability and Accountability Act (HIPAA). Those federal audits are in addition to the inspections that state survey teams have now been ordered to conduct.
Case points to Business Associate Agreements as critical
When it comes to HIPAA enforcement, you can’t hide behind a cloak. That is the message of the federal government’s settlement with the Archdiocese of Philadelphia.
The Diocese will pay $650,000 to settle potential violations under the Health Insurance Portability and Accountability Act (HIPAA), relating to the theft of a mobile device containing protected health information for 412 nursing home residents.
In this and other recent actions, the feds are underscoring an emphasis on holding Business Associates accountable for safeguarding patient information.
In the Philadelphia case, Catholic Health Care Services (CHCS), an agency of the Diocese, performed IT services as a business associate to six skilled nursing facilities. Here is what happened, according to an announcement by the U. S. Office for Civil Rights (OCR):
In April 2014, ORC initiated an investigation following the theft of a CHCS-issued employee iPhone. The iPhone was unencrypted and was not password protected. The information on the iPhone included social security numbers, information about diagnoses, medications and treatments, and names of family members and legal guardians.
Investigators found that CHCS had no policies addressing the removal of mobile devices containing patient information from its facility, and no risk analysis or risk management plan.
The feds signaled they went light on the settlement amount, saying they considered that CHCS provides much-needed services in the Philadelphia area.
The Resolution Agreement and Corrective Action Plan can be found on the OCR website at:http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/catholic-health-care-services/index.html.
In a memo released last month, the U.S. Office for Civil Rights (OCR) raised this question: Is Your Business Associate Prepared for a Security Incident?
Well, how would you answer?
The issue is critical, as OCR audits are in progress under the federal Health Insurance Portability and Accountability Act (HIPAA). The audits extend to business associates, and according to OCR, business associates will need to demonstrate security risk analysis, risk management, and breach reporting procedures.
In its memo, OCR refers to a widespread perception that it is difficult for healthcare providers to know whether their business associates are adequately protecting patient information.
First, let's make sure you know who your business associates are. In sum, a business associate is any outside person or company with whom you share protected health or personally identifiable information about the people you serve.
They -- through you -- are obligated to meet all federal privacy and security laws to protect that information. This includes billing companies, technology vendors, temporary staffing companies and anyone else with potential assess to patient information. With all of your business associates, you need an agreement that legally binds you (the HIPAA covered entity) and the business associate with very clear terms for managing and protecting health information emanating from you.
In its new memo, OCR also says you should plan in advance for how you will confront a breach by a business associate, including subcontractors. OCR’s memo recommends the following:
1. Business associate agreements should define how and for what purposes patient information may be used or disclosed. Be clear about what constitutes unauthorized disclosures and incidents that need to be reported back to the HIPAA-covered healthcare provider.
HIPAA defines “security incidents” as attempted or successful unauthorized access, use, disclosure, modification, or destruction of information, or interference with system operations in an information system. This could include:
2. Business associate agreements should specify the time frame for business associates or subcontractors to report a breach, security incident, or cyber-attack. Keep in mind: Reporting should be prompt, and covered entities are liable for untimely HIPAA breach reporting to affected individuals, OCR and, in some cases, the media.
The federal government’s website says that HIPAA-covered providers should file a breach notification by filling out and electronically submitting a breach report form to the U.S. Department of Health and Human Services.
If a breach affects 500 or more individuals, covered entities must file a report promptly, and in no case later than 60 days following a breach. If a breach affects fewer than 500 individuals, the covered entity must submit notification no later than 60 days after the end of the calendar year in which breach is discovered. The government’s website also describes circumstances that require reporting to the media.
3. Business associate agreements should identify the type of information a business associate or subcontractor will need to provide in a breach or security incident report. Such reports should include the business associate’s name and point of contact information, and descriptions of:
4. Finally, covered entities and business associates should train workforce members on incident reporting. OCR says covered entities may want to conduct security to make sure their business agreements are being enforced.
Read about the first criminal charges under HIPAA law, in a commentary by MyHIPAA Guide Publisher Diane Evans, in the June 2016 issue of Compliance Today: