Even organizations with sound policies, procedures, training, and safeguards can experience a breach. When?not if?a breach occurs, traditional insurance may not be enough to cover the damages. Ensuring that your organization has adopted the appropriate cyber insurance can be valuable in the event of a breach.
The Office for Civil Rights (OCR) announced December 8, 2014 that it fined an Alaska behavioral health service $150,000 for potential HIPAA violations. OCR entered into a resolution agreement with Anchorage Community Mental Health Services (ACMHS), a nonprofit behavioral healthcare service, per the announcement (see www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/acmhs/amchs-capsettle...).
There are many misconceptions about HIPAA throughout the healthcare industry. In particular, business associates (BA) who provide cloud services to covered entities (CE) often have the misconception that they do not need to be concerned with HIPAA if they are compliant with the Payment Card Industry Data Security Standard (PCI-DSS). BAs with this school of thought should be prepared to get their checkbooks out when the Office for Civil Rights (OCR) comes calling.
Q: As part of the audit controls policy at my organization, we hired an external security vendor to collect and review logs from several critical servers. The vendor creates tickets for our IT staff when a potential incident is discovered during the daily log review. This supplements our own activity reviews of internally generated reports, and the vendor then uses them for its own review. Our internal staff never sees the reports the vendor uses for its review. Do the reports the vendor uses fall under the HIPAA requirement for retaining logs for six years? Should we compel the vendor to retain these reports?
At this point, there are no federally recognized HIPAA certification standards for covered entities (CE) and business associates (BA). However, that doesn't mean there are no good assessment tools out there to gauge information security and regulatory compliance. The Health Information Trust Alliance (HITRUST) published its first common security framework (CSF) in March 2009 with the goal of focusing on information security as a core pillar of the broad adoption of health information systems and exchanges.
Q: I was recently hired for a position at a long-term care facility. Upon getting acclimated, I learned that the facility has completed handwritten logs for every fax that was sent out since 2003. This document is referred to as the HIPAA fax log and contains the date the fax was sent, to whom it was sent, by whom it was sent, the number of pages, and whether a cover sheet with confidentiality statement was included. I would like to do away with this form since fax machines can generate their own logs. However, if this is a necessary process then I would like to follow official guidelines and update the facility's policies and procedures accordingly. Does the HIPAA Privacy or Security Rule require these logs? If so, what information must we include?
While organizations should focus on performing regular risk assessments and analyses, there are also other ways in which they must review their systems for compliance. Often, these other evaluations are overlooked despite their value, says Kevin Beaver, CISSP, an information security consultant in Atlanta. In particular, organizations should be careful not to forget about performing vulnerability assessments and penetration tests, which are components of an overall risk assessment or analysis, says Beaver, who is a BOH editorial advisory board member.
