Kimberly Shutters

Your Employee Just Quit! You receive a call from the front desk explaining that one of your workforce members just quit. What do you do? The first thing you do, pull out your termination standard operating procedure (SOP). The SOP should include the necessary Workforce Security Termination Procedures for you to follow. What Does the HIPAA Security Rule Say? The Termination procedures is an addressable Administrative Safeguard, as defined below §164.308 (a)(3)(ii)(C). Implement procedures for terminating access to electronic protected health information (PHI) when the employment of, or other arrangement with, a workforce member ends or as required by determinations made as specified in paragraph (a)(3)(ii)(B) [the Workforce Clearance Procedure] of this section. Administrative Safeguards In case you did not already know over half of the HIPAA Security Rule is comprised Administrative Safeguards, they are defined as: Administrative actions, and policies and procedures, to manage the selection, development, implementation, and maintenance of security measures to protect electronic PHI and to manage the conduct of the covered entity’s workforce in relation to the protection of that information. For more details on Administrative Safeguards see our article on where I breakdown for you. Why Do Termination Procedures Matter? When a workforce member leaves, it is extremely important for regulated entities of all sizes prevent unauthorized access to PHI. This is accomplished by terminating the former workforce member’s access to PHI. Don’t forget to ensure all company owned mobile devices like laptops and smartphones are returned. Also, if you allow the use of PHI on personally owned phones or other devices is permitted, be sure those devices are cleared or purged of electronic PHI. Termination Procedures Termination Procedures should include: Procedures to terminate access to PHI should also include termination of physical access to facilities. Procedures to terminate physical access could include:→ Changing combination locks and security codes→ Removing users from access lists, and ensuring the return of keys→ Tokens→ Keycards, ID badges→ And any other physical items that could permit access to secure areas with PHI Have standard termination procedures of all action items to be completed when an individual leaves, these action items could be incorporated into a checklist. These should include notification to the IT department or a specific security individual of when an individual should no longer have access to PHI, when their duties change, they quit, or are fired. Consider using logs to document whenever access is granted (both physical and electronic), privileges increased, and equipment given to individuals. These logs can be used to document the termination of access and return of physical equipment. Consider having alerts in place to notify the proper department when an account has not been used for a specified number of days. These alerts may be helpful in identifying accounts that should be permanently terminated. Terminate electronic and physical access as soon as possible. De-activate or delete user accounts, including disabling or changing user IDs and Have appropriate audit procedures in place. Appropriate audit and review processes confirm that procedures are being implemented, are effective, and that individuals are not accessing PHI when they shouldn’t or after they leave. Address physical access and remote access by implementing procedures to:→ Take back all devices and items permitting access to facilities (like laptops, smartphones, removable media, ID badges, keys)→ Terminate physical access (for example, change combination locks, security codes)→ Effectively clear or purge PHI from personal devices and terminate access to PHI from such devices if personal devices are permitted to access or store PHI→ Terminate remote access capabilities→ Terminate access to remote applications, services, and websites such as accounts used to access third-party or cloud-based services Change the passwords of any administrative or privileged accounts (like admin or root user) that a former workforce member had access to. Something to Ponder … Ask yourself the following two questions: Does your organization have current termination policies and procedures? Does your organization’s policies and procedures include timely communication of termination actions to ensure that the termination procedures are appropriately followed?

HIPAA Rules – Who Has To Comply? Back in 2013, HIPAA rules were updated when the final Omnibus Rule became effective on March 26, 2013. I know that seems like ancient history to most, but really it was less than 10 years ago. That’s how long it has been since third-party vendors, referred to as Business Associates (BAs), of all sizes have been required to comply with HIPAA Privacy, Security, and Breach Notification Rules. These days most healthcare providers and health plans do not carry out all of their healthcare activities and functions by themselves. Instead, they often use the services of a variety of other individuals or businesses. Health & Human Services (HHS) defines this type of service provider as a BA, as defined in 45 CFR 160.103. HIPAA Rules – What Do the Rules Say? Covered Entities (CEs) and BAs, collectively referred to as regulated entities, in accordance with § 164.306:  Must ensure the confidentiality, integrity, and availability of all electronic protected health information (ePHI) the regulated entity creates, receives, maintains, or transmits on the CE’s behalf only if the CE obtains satisfactory assurances, in accordance with § 164.314(a) that the BA will appropriately safeguard the information. Every CE must document that their BAs are HIPAA compliant, this requirement includes documentation of their workforce training, and they have HIPAA compliant security policies in place and that they there is an incident reporting procedure in place between your practice and the BA. And remember to document your findings – If it’s not documented, it didn’t happen! After all, an auditor might ask you for the data. Covered Entities Any healthcare provider, health plan, or healthcare clearinghouse that transmits any information in an electronic form in connection with transactions for which HHS has adopted a standard. For example, hospitals, academic medical centers, physicians, pharmacies, and other healthcare providers who electronically transmit claims transaction information directly or through an intermediary to a health plan are covered entities. CEs can be institutions, organizations, or individuals. Third-Party Vendors Third-party vendors, referred to as BAs, is a person or entity including subcontractors, other than a member of the workforce* of a CE, who performs functions or activities that involve access by the BA to PHI. BAs are also subcontractor that creates, receives, maintains, or transmits protected health information (PHI) on behalf of another BA.  *Note: Anyone paid with a 1099 freelancer/contractor is not a member of your workforce. Be sure your organization is following the 1099 Freelancer/Contractor IRS Rules.  Subcontractors An entity to which a BA delegates a function, activity, or service, other than as a member of the BAs workforce. There is no limit to the number of subcontractors that may be liable, because a subcontractor might delegate functions to other subcontractors, creating a chain of BA entities. Covered Entities and their third-party vendors should understand that patients are entrusting them with their most private and intimate details, they expect it to remain secure. Besides, it is YOUR practice, YOUR patients, YOUR reputation and YOUR legacy! Why are you leaving yourself wide open to such risks?

Addressable and Required: Know the Difference When it comes to the HIPAA Security Rule Covered Entities (CEs) and their third-party vendors, referred to as regulated entities by the Department of Health and Human Services, are required to comply with every Security Rule “Standard.” Some of those standards are categorizes are addressable and required. Addressable and Required Breakdown The HIPAA Security Rule contains several implementation specifications that are labeled as Addressable or Required specifications. Required – If an implementation specification is described as “required,” the specification MUST be implemented. Addressable – The concept of “addressable implementation specifications” was developed to provide providers and their third-party vendors additional flexibility with respect to compliance with the security standards. One important thing to remember, “addressable” designation does not mean that an implementation specification is optional. HHS to the Rescue Luckily HHS has come to our rescue in the response to the following frequently asked question: “What is the difference between addressable and required implementation ns in the Security Rule?” Below is a breakdown of their response: If the standard is not reasonable and appropriate, the Security Rule allows the regulated entity to adopt an alternative measure to achieve the purpose of the standard if the alternative measure is reasonable and appropriate 45 C.F.R. § 164.306(d). In meeting standards that contain addressable implementation specifications, a regulated entity will do one of the following for each addressable specification: Implement the addressable implementation specifications Implement one or more alternative security measures to accomplish the same purpose Not implement either an addressable implementation specification or an alternative Each regulated entity must evaluate whether a given addressable implementation specification is a reasonable and appropriate security measure to implement within their particular security framework. HHS provides the following example: A regulated entity must implement an addressable implementation specification if it is reasonable and appropriate to do so and must implement an equivalent alternative if the addressable implementation specification is unreasonable and inappropriate, and there is a reasonable and appropriate alternative. The decision to implement an addressable implementation specification will depend on a variety of factors, such as, among others, the entity’s risk analysis, risk mitigation strategy, what security measures are already in place, and the cost of implementation. It’s All in the Documentation Don’t forget each choice must be documented. After all you don’t want the HHS auditor to say “I find your lack of documentation disturbing.” The decisions a regulated entity makes regarding addressable specifications must be documented in writing. Written documentation should include the factors considered as well as the results of the risk assessment (analysis) on which the decision was based. Something to Ponder The HIPAA security risk analysis process is an opportunity to learn as much as possible about the health of your information security. Don’t ignore your need to be HIPAA compliant! Any device or media that contains protected health information (PHI) needs to be properly protected – HIPAA is not system or hardware specific – it applies to all!