© HIPAA Continuity Planners HIPAA Mandates a PLAN! (beyond hardware and software) Presented in Partnership with

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© HIPAA Continuity Planners HIPAA Mandates: Risk Analysis Continuity Plan Security Procedures An Incident Response Plan Contact Procedures Documentation Employee Training

© HIPAA Continuity Planners Processes and Procedures Risk Analysis Process of identifying possible external and internal conditions, events or situations, determination of causal relationships between probable happenings, their magnitude with likely outcomes, as they might effect the continuing operation of the office.

© HIPAA Continuity Planners Processes and Procedures Continuity Plan Set of documents, instructions, and procedures which enable a business to respond to accidents, disasters, emergencies, and threats without any stoppage or hindrance in its key operations. Business resumption plan, disaster recovery plan, or resilience plan* * From BusinessDictionary.com

© HIPAA Continuity Planners Processes and Procedures Security HIPAA mandates security procedures for: Premises Access Computer Access authorization Server Access Log-in Monitoring Password management Health information sharing Termination procedures Compliance Tracking Software with logs Business Associates

© HIPAA Continuity Planners Processes and Procedures for Incident Response Plan Some steps of the IRP may include the following: Define the incident – what happened? When did it happen? Who was involved? When was it discovered? Stop the incident – if a smartphone is lost take the steps to disable the access, if a breach is found take the steps to prevent further access, etc. Document the incident – fill in all the details of what occurred from step 1 (define the incident) and step 2 (steps taken to stop the incident). Clearly document all aspects of the incident.

© HIPAA Continuity Planners Processes and Procedures for Incident Response Plan Notify appropriate individuals / agencies –the amount of patient records affected will determine what notification steps are needed. Individual patients and Health and Human Services (HHS) will need to be notified. In addition, local media may need to be notified as well. Provide guidance to prevent the incident from occurring again – an important aspect of an incident response is to ensure that the same incident does not happen in the future. Recommendations to increase security and reduce the risk of an incident are essential.

© HIPAA Continuity Planners Processes and Procedures Contact Plan Establish: Procedures to contact employees via telephone, text and/or in case of office closing. A copy of employee emergency notification outside of the office A copy of patient contacts for daily appointments be available outside the office for notification of an office closing.

© HIPAA Continuity Planners Documentation HIPAA required documentation: Risk Analysis Written Continuity Plan Security Procedures Emergency operation mode plan Periodic Evaluations Compliance Tracking Software with logs

© HIPAA Continuity Planners Training Security Awareness Training Computer Security Incident Command Evacuation Procedures and Responsibility Basic HIPAA Requirements Employee buy-in through understanding

© HIPAA Continuity Planners Tier A is for violations in which the offender didn’t realize he or she violated the Act and would have handled the matter differently if he or she had. This results in a $100 fine for each violation, and the total imposed for such violations cannot exceed $25,000 for the calendar year. Tier B is for violations due to reasonable cause, but not “willful neglect.” The result is a $1,000 fine for each violation, and the fines cannot exceed $100,000 for the calendar year. Tier C is for violations due to willful neglect that the organization ultimately corrected, and the fines cannot exceed. The result is a $10,000 fine for each violation $250,000 for the calendar year. Tier D is for violations of willful neglect that the organization did not correct. The result is a $50,000 fine for each violation, and the fines cannot exceed $1,500,000 for the calendar year. The HITECH Act allows states attorneys general to levy fines and seek attorneys fees from covered entities on behalf of victims. Courts now have the ability to award costs, which they were previously unable to do. HIPAA/HITECH Penalties

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© HIPAA Continuity Planners Questions? A.J. (Andy) Weitzberg President Ofc Cell