Committee Meetings and Minutes

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HIPAA Task Force Committee

Meeting Minutes

Current Status of Minutes: Final
Date	November 10, 2011
Time	11:30 AM - 1:30 PM
Location	EVC 8358

Members Present
Ross Greves, Eileen Klein, Douglas Mitchell, Training Officer, Kellie Murphree, Susan Pearce, Marilyn Rehm-Skewis, Support Staff, Robyn Richter, Nancy Walters, Privacy Officer
Guests Present
Antonio (Tony) Martinez Representing Adjunct Faculty Associa, Lara Niles, President APTE- Frof-Tech Association, Michael Hill IT Substitute for Theresa Harkins

Item # 1:	Introductions:
Presenter	Patricia Recek
Discussion	Discussion: > Committee Chair Pat Recek welcomed members and guests. > A short explanation to the HIPAA Task Force Committee for extending an invitation to the ACC Associations was discussed. > Committee Chair requested attendees to introduce themselves and the department they represent. > A short review of the history of the ACC HIPAA Task Force Committee was discussed for all. Decision/Actions: * None

Item # 2:	Approval of Agenda
Presenter	Patricia Recek
Discussion	Decisions/Actions: * Agenda approved by committee Handouts: Agenda – HIPAA Task Force Meeting Agenda for November 10, 2011 (one page) Proposed Compliance Review Schedule Spring 2010 through Spring 2013, (three pages) HIPAA Committee Information Sheet, from www.austincc.edu/orgref/councils/hipaa.php, (two pages) Shared Governance Structure, 2011 – 2012, (one page) Administrative Rules, www.austincc.edu/admrule/3.01.005.htm, (one page) ACC Shared Governance Membership Structure, FY12, Councils & Committees, (one page) HIPAA Task Force Minutes from 2011, February 23, (four pages) Information Emailed to committee members before 2011, November 10 meeting: HIPAA Task Force Minutes from 2011, February 23, (four pages) National Council of State Boards of Nursing (NCSBN) White Paper: A Nurse's Guide to the Use of Social Media, (7 pages)

Item # 3:	Approval of February 23, 2011 minutes
Presenter	Patricia Recek
Discussion	Discussion: > Minutes were emailed to committee members after last meeting for initial review. . > Minutes available at meeting for review. Decisions/Actions: * Minutes were approved by committee.

Item # 4:	Old Business A. Compliance Reviews - Update B. HIPAA Training Module Update C. Follow up on training modules based on job responsibilities (EHS) B. HIPAA Training Module Update C. Follow up on training modules based on job responsibilities
Presenter	Patricia Recek
Discussion	Discussion: > Committee Chair reported that the first cycle of compliance reviews for all HIPAA components was to be completed by August 2011. Reports/reviews that remain outstanding are to be completed by end of fall 2011 because the next cycle begins in spring 2011. The outstanding reviews/reports include: Accounts Payable, Cashier's Office, Human Resources, Massage Therapy/CE HPI, and Personal Fitness Training. > The Office of Civil Rights will be performing random audits of covered entities November 2011 through December 2012. ACC Health Sciences programs could be involved as Business Associates of the facilities we are associated with, example hospitals that provide clinical sites for our students. Ensuring that faculty, students, and staff are trained regarding HIPAA is one of the critical elements of ACC's responsibilities as a Business Associate. Compliance reviews of programs are critical to ensuring programs are monitoring compliance and maintaining the required records. Decisions/Actions: * Compliance Reviews would be turned in by those individuals who did not submit their review. Follow-up Items: > New compliance Review Assignments for spring 2012 Person responsible: Pat Recek Deadline: End of Semester > Late Compliance Review/Report Person assigned to following departments: Accounts Payable, Cashier's Office, Human Resources, Massage Therapy/CE HPI, and Personal Fitness Training. Deadline: As soon as possible. B. HIPAA Training Module Update Discussion: 1. Concerns expressed related to the delay in posting of completion of HIPAA module on Professional Development records for individuals who take the HIPAA test > Possible reasons for posting delays were discussed > Procedures and professional development links form test site to Individual Professional Development records were discussed. One possible delay is any grading that needs to be done to ensure that the person achieved the required score on the post test. The HIPAA module will not let the individual complete until they answer all questions correctly- this may enable faster online documentation of completion. Individual still must sign and submit the confidentiality form to their supervisor. Decisions/Actions: * Guest Lara Niles will follow up on concerns the committee had about posting HIPAA training to individuals Professional Development records. Follow-up Items > Online training posting to Professional Development Person responsible: Laura Niles Deadline: February 2012 meeting Discussion: >Numerous concerns were expressed by students, faculty, and staff related to the answers to one question on the HIPAA test module. The question was identified unclear for those who took the test. The question was removed from the test. No other concerns have been identified. C. Follow up on training modules based on job responsibilities (EHS) Discussion: > Previous discussions focused on the need to have all staff and faculty HIPAA trained; discussions stemmed from a variety of disclosures made by staff. The committee determined that many of the disclosures were not HIPAA violations but were more confidentiality issues so mandatory HIPAA training for everyone may not be a reasonable approach. >B. Cole reported in the last (April 2011)meeting the EHS is getting software that links specific training to job responsibilities and she would explore whether HIPAA could be rolled into that process. Additional departments have been added to the required HIPAA training based on the likelihood of accessing PHI. Becky Cole was not available to report. Decisions/Actions: * P. Recek will follow up with B. Cole * Discuss at next meeting

Item # 5:	V. New Business A. Request by SGA to have student representative B. Social Media Scenarios for Training B.Social Media Scenarios for Training
Presenter	Patricia Recek
Discussion	Discussion:>Brief history of committee formation/structure presented. * HIPAA originally a "Task Force" that reported to the president. All members were appointed Ex Officio because of their roles. In the last few years, the committee has been placed under the Austin Community College Administrative Services Council. >The Student Government Association (SGA) contacted Chair about appointing a SGA representative to the committee. The current published ACC Shared Governance Membership Structure, FY12 does not list HIPAA in the table identifying the number of representatives for each membership group. >P. Recek contacted Tobin Wiegnand , Co-Chair of the Shared Governance Review Council. He states: The SGA and all employee organizations have been asked to send any requests for change in Council/Committee membership or structure to the SGRC. The SGA needs to make the request to the SGRC. The Council will consider requests and forward them to the President. All requests will be forwarded to the President for consideration whether the Council supports the request or not. We tend to strongly encourage student participation in the SG process. The fact that the HIPPA committee is not opposed to SGA membership adds weight to the request". These requests are due in September. > Discussed the background that would best suite the committee, example: representatives with a Health Science Department versus a representative from an English Department. > Tony Martinez, representative from the Adjunct Faculty Association, as a guest of the committee, expressed his interest in the committee and his roll in Health Science and HIPAA. > Changes in committee procedures that should take place with student on committee, example: De-identify HIPAA breach information. > Discussed request for confidentiality disclosure. * Decisions/Actions:Committee approved a student representative from student government and association representatives. * Committee would like to suggest a Student Government Health Science Department student representative if the appointment by the college is approved. Follow-up Items: > A letter supporting the addition of a student representative from student government and association representatives will be sent to Tobin Wiegand. Person responsible: Pat Recek Deadline: January, 2012 The organizations will need to follow the established processes for inclusion on the HIPAA committee. Both employee group representatives present indicated they will follow through with their individual organizations. Person/s responsible: Lara Niles, President APTE- Prof- Tech Association Antonio (Tony) Martinez, Representative Adjunct Faculty Association Deadline: No Deadline B. Social Media Scenarios for Training Discussion: > National Council of State Boards of Nursing (NCSBN) White Paper: A Nurse's Guide to the Use of Social Media - emailed to committee and passed out to guests: discussed. This publication includes excellent actual examples of violations of HIPAA using social media. Permission was received from NCSBN to use some of the scenarios in the ACC HIPAA Training Module with credits given to NCSBN.. > Several committee members expressed how informative the document was and approved the use. Decisions/Actions: * Committee members approved adding the examples of the White Paper to the HIPAA Training Module giving credit to the NCSBN. * Committee Chair with the help of the HIPAA Training Officer, would add examples from the NCSBN White Pater to the ACC HIPAA Training Module, giving credit to the NCSBN. * Committee Chair suggesting providing a link to the NCSBN White Paper. Follow-up Items: Add examples from the NCSBN White Paper to the ACC HIPAA Training Module. > Add a link to the NNCSBN White Paper on the HIPAA web site. Person responsible: Pat Recek, Chair and Doug Mitchell, Training Officer Deadline: No Deadline

Item # 6:	HIPAA Events
Presenter	Patricia Recek
Discussion	Discussion: None to report

Item # 7:	Miscellaneous
Presenter	Patricia Recek
Discussion	Discussion: > Eileen Klein announced that the CBS's Auditor for Criminal Background Checks were on campus this week. > Eileen Klein discussed the legal conference she attended prior to the meeting. She gave examples of incidents with social media. > IT Security Michael Hill discussed IT security measures. > Laura Niles Discussed Cloud Doc > Ross Greves discussed ACC safety measures. Decisions/Actions: * None Follow-up Items: None

Item # 8:	Next Meeting
Presenter	Patricia Recek
Discussion	Next Meeting Date: Thursday, February 23, 2012 Time: 11:30 a.m. – 1:30 p.m. Location: EVC, Bldg 8000, Room 8358 EVC, Bldg. 8000, Room 8358

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