Committee Meetings and Minutes

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HIPAA Task Force Committee

Meeting Minutes

Current Status of Minutes: Final
Date	February 23, 2012
Time	11:30 AM - 12:45 PM
Location	EVC 8358

Members Present
Susan Corbett, Renee Cornett, Security Officer, Ross Greves, Theresa Harkins, Jana Israel, Eileen Klein, Douglas Mitchell, Training Officer, Kellie Murphree, Susan Pearce, Marilyn Rehm-Skewis, Support Staff, Regina Swearengin, Nancy Walters, Privacy Officer
Guests Present
Dave Watkins, Coordinator, Environmental Health & Safety, Laura Niles, President, APTE-Prof-Tech Association

Item # 0:	Handouts: HIPAA Compliance Review Schedule for 2013 with updates for 2010 & 2011 REviews
Presenter	Patricia Recek
Discussion	HIPAA Compliance Review Schedule for 2013 with updates for 2010 & 2011 Reviews

Item # 1:	Approval of Agenda
Presenter	Patricia Recek
Discussion	Discussion: None Decision/Actions: Agenda approved by committee

Item # 2:	Approval of November 10, 2011 minutes
Presenter	Patricia Recek
Discussion	Discussion: Minutes were held until end of committee meeting to allow members to review before approval. Decisions/Actions: Minutes approved by committee members

Item # 3:	Old Business * Update on use of MSDS Training for HIPAA-Non Health Sciences
Presenter	Patricia Recek
Discussion	Discussion: Mr. Watkins, a Coordinator with EHS, reported on the MSDS Training package that was purchased by ACC to provide required training across the spectrum for ACC employees. The committee is considering a recommendation to use this system for HIPAA training for the non-health sciences components required to do HIPAA training. Health Sciences faculty and students must use the training developed by Seton and St. David's. There are two (2) HIPAA training programs included in this package. The company can also integrate a school's current training into the system. The two HIPAA training program are: (1) Health Care Provider (2) Health Care Plans and Employer The system is being designed to interface with the professional development records; Mr. Watkins also thought there was a mechanism for automatic reminders. Each training program is capable of keeping records of participation and test scores. The college will be able to identify certain "employee groups or departments" and the training they are required to have. Pat Recek reported she had taken both of the HIPAA training courses. They are very thorough, but do take some time to complete. They do not have to be completed at one sitting. Committee members were able to review briefly one of the tests online. .. The program includes audio, has questions interspersed in the presentation, and at the end of each module is an evaluation that must be completed with an acceptable score before the person can move forward. David Watkins offered to enroll all HIPAA committee members in the courses so they could review them more thoroughly - Questions and Answer session on the test program by committee members. The consensus of the group was that if the committee is going to recommend using the MSDS system for the non-health sciences departments, we would recommend using the HIPAA training from the company because it would ensure current information as laws changed, Decisions/Actions: David Watkins will enroll Committee Members to take the HIPAA training. Follow-up Items: >HIPAA Task Force Committee Member email addresses will be sent to David Watkins to allow him to sign the member up to take the HIPAA training. Person responsible: Patricia Recek Deadline: Month of March 2012 > Sign up HIPAA Task Force Member to take the HIPAA training. Person responsible: David Watkins Deadline: Month of March 2012 >Committee Members will take the HIPAA training and send comments to Pat Recek Person responsible: HIPAA Committee Members Deadline: May 2012 >Comparison of current HIPAA training to new HIPAA training > HIPAA updates on training program by MSDS Person Responsible: David Watkins Deadline: Next Meeting

Item # 4:	Old Business * Compliance Reveiws
Presenter	Patricia Recek
Discussion	Discussion: Discussion included the status of the compliance reviews and the item of new business to look at recommended intervals for review. Three departments remain to be reviewed under the 2010 Plan and will be completed this spring: Massage Therapy, Accounts Payable and Human Resources, see handout "HIPAA Compliance Reviews" Pat Recek reported that a review of recommendations by CMS indicate that best practices for review is at least every three years. A draft schedule for three year reviews was presented for review. Decisions/Actions: * A motion was made and seconded that compliance reviews the HIPAA Components would be every three years. Committee Approved unanimously. Follow-up Items: >Compliance Reviews for three department this spring Person responsible: Pat Recek Deadline: Spring 2012

Item # 5:	New Business * Intervals for training for required groups
Presenter	Patricia Recek
Discussion	Discussion: The current HIPAA guidelines state that Health Sciences will conduct annual HIPAA training. Non-HS HIPAA components did HIPAA training at the implementation of HIPAA laws and upon hire for new employees. Review of CMS recommendations indicate that annual training is appropriate for all employees who may have contact with PHI. Discussion revolved around the process needed to move this recommendation forward. It may need to be a guideline to accompany the Administrative Rule. The process will begin now because it may take some time to go through the shared governance process of the college. Implementation would be targeted to the implementation of the MSDS training process (Fall 2012 at the earliest). Decisions/Actions: * Motion made to require annual HIPAA training for all departments identified as HIPAA components. Motion passed by committee Follow-up Items > Begin process for moving this recommendation forward. Person responsible: Pat Recek Deadline: Start paperwork March 2012

Item # 6:	New Business * Time frame for compliance audits
Presenter	Patricia Recek
Discussion	Discussion: *See recommendations under Old Business-Compliance Reviews

Item # 7:	New Business * Systematic Review of Policies
Presenter	Patricia Recek
Discussion	Discussion: CMS also recommends a systematic review of policies. No time reference was made. P Recek recommended a three year cycle or more frequently if the law changes. Changes were made to the ACC HIPAA website with the implementation of the HITECH Act. Will look at this at the fall meeting. Will have committee review the current policies before that meeting. Decisions/Actions: Will review policies in fall and then every three years or sooner if laws change. Follow-up Items: > Plan for policy review for fall meeting. Person responsible: Pat Recek Deadline: Fall 2012

Item # 8:	HIPAA Events
Presenter	Patricia Recek
Discussion	Discussion: ADN student turned in paperwork to faculty on the unit that contained PHI. The information did not leave the hospital. Decisions/Actions: Pat reported that the privacy was not violated but student was put on probation and the event was put in the students file. Follow-up Items > None

Item # 9:	Miscellaneous
Presenter	Patricia Recek
Discussion	Discussion: With the college's adoption of Google Docs, the college has seen faculty and staff sharing information with the public that may not be appropriate. IT has a tool that automatically monitors for public shared documents and generates a report to the college on a weekly basis. Teresa Harkins Questioned one of these alerts as being a possible HIPAA violation. Upon review, it was a nursing care plan shared between a faculty and student. It did not have the patients name but had information that could lead to the identity of the person. It had been shared by the faculty to the non-ACC email of the student. Theresa will forward any of these reports to P. Recek. Decisions/Actions: Review possible HIPAA violations brought to Ms. Harkins attention by contractor who audits emails. Review after current meeting and consider possible action. Follow-up Items: >Examples of possible HIPAA breach reported by Contractor who analysis emails. P. Recek will follow up with that faculty and department chair. Person responsible: Teresa Harkins/Pat Recek Deadline: ASAP

Item # 10:	Next Meeting
Presenter	Patricia Recek
Discussion	TBA – Fall of 2012 Time: 11:30 a.m. – 1:30 p.m. Location: EVC, Bldg. 8000, Room 8358

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Austin, Texas 78752-4390
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