Committee Meetings and Minutes

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HIPAA Task Force Committee

Meeting Minutes

Current Status of Minutes: Final
Date	November 15, 2012
Time	11:30 AM - 1:00 PM
Location	EVC, Bldg 8000, Third Floor, Room 8358

Members Present
Rebecca Cole, Sanctions Officer, Susan Corbett, Renee Cornett, Security Officer, Ross Greves, Eileen Klein, Durwood (Alex) Matthews, Kellie Murphree, Marilyn Rehm-Skewis, Support Staff, Robyn Richter, Nancy Walters, Privacy Officer
Guests Present
Jerald Lewis, EMSP Student, Tobin Wiegand, President Classified Association ACCCEA

Item # 1:	Approval of Agenda
Presenter	Pat Recek
Discussion	Discussion:  Robyn Richter - Motion to approve agenda as written  Eileen Klein second the motion to approve agenda Decision/Actions: * Committee approved agenda as is.

Item # 2:	Approval of February 23, 2012 minutes
Presenter	Committee Members
Discussion	Discussion:  Renee Cornett - Motion to approve minutes for February 23, 2012 as is.  Eileen seconds the motion to approve minutes for February 23, 2012 as is. Decisions/Actions:  Committee approved minutes as is Follow-up Items: None

Item # 3:	Old Business - HIPAA and Shared Governance
Presenter	Pat Recek
Discussion	Discussion:  Ms. Recek welcomed the new faces attending the committee meeting. See changes in the members listed under the heading above: Attendees.  Ms. Recek gave a brief explanation of the committee and shared governance at ACC.  Ms. Recek explained briefly the Organizational Guidelines for the Business Associate, Non-Business Associates and Covered Entities Decisions/Actions:  New members were welcomed

Item # 4:	Old Business - Update on use of MSDS Training for HIPAA-Non Heatlh Sciences
Presenter	Pat Recek
Discussion	Discussion: Update on use of MSDS Training for HIPAA – Non Health Sciences  A brief review of the structure of the HIPAA components at ACC was presented by P. Recek for new members. Becky Cole provided an update on the MSDS Training package that was purchased by ACC to provide required training for ACC employees.  Last spring, committee members were given access to and asked to review the two HIPAA modules available from the company, Health Care provider and the Health Care Plans and Employers. To determine if one could be used for ACC non – health sciences training purposes. Consistent feedback from the committee was that the training was too long and more detailed than needed to meet the needs of the non-Health Sciences departments that require training.  Becky Cole indicated that ACC could use its current training module (non-health sciences) and upload it into the MSDS system. This would enable reminders to be sent to employees to redo training as necessary.  Work is ongoing to synchronize the MSDS system and Professional Development documentation system. o Discussed concerns on how fast an employee receives confirmation on professional development after taking training, and whether the results have to be put into individuals files manually or if it is automated. o Ms. Shopland indicated that the turn-around time can be related to how the program is set up for feedback.  Robin Richter had concerns with adapting the Health Sciences training to the MSDS system; the tracking of compliance with HIPAA is driven by each individual program and using the MSDS could result in delayed verification of compliance with clinical requirements. o Important to note that the training developed for Health Sciences students, faculty, and staff was developed in collaboration with the clinical partners and can be added to but no items can be deleted. Decisions/Actions:  Committee was in agreement to move forward with aligning the non-Health Sciences training with the MSDA training system. The current process for verification of Health Sciences training will remain unchanged. Follow-up Items Person responsible: Pat Recek and Becky Cole Deadline:

Item # 5:	Old Business - Compliance Reviews: * Systematic Review of Policies-CMS also recommends a regular review of policies- no time reference but suggest every 3 years- will do in fall. We updated some aspects of website in Fall 2010 with the implementatio
Presenter	Pat Recek
Discussion	Discussion: Compliance Reviews: Timelines for continuing compliance reviews were discussed at the Feb. 2012 meeting with an agreement to conduct these on a three year cycle unless there are significant changes in the law.  All audits/ reviews were completed  Ms. Recek explained the HIPAA Department Audit and how the audit ensures that each department is compliant with requirements. The Task Force Committee had a plan to review each department every three which aligns with Center for Medicare (CMS) recommendation. The Programs/Departments due for a Fall 2013 Review are as follows: Dental Hygiene, ADN, EMSP, Medical Coding, MlT/Phlebotomy, OTA, Pharmacy Technician, PTA, Radiology, Surgical Technology, Vocational Nursing, Child Development Center, EHS, and Human Services. The one area for development for many programs was employee/faculty documentation of training and maintenance of that documentation for six years to be in compliance with the law. A Systematic Review of Policies is also recommended to be done on a regular basis, with a three year cycle given as a recommendation by CMS. The ACC HIPAA website was updated in Fall 2010 with the implementation of HITECH and last spring included links to the Social Media Guidelines of the ANA. P. Recek will review and make recommendations for any additions or revision in Jan. 2013. Some recommendations include:  Clear information related to the HITECH Act.  New audit/review checklists.  Link to the new Texas Privacy Law Decisions/Actions:  Proceed with three year plan with making sure all web sites are current and reviewed by the HIPAA Committee. Follow-up Items >Review web sites for the department concerning HIPAA- Spring 2013. Audits/reviews to proceed with schedule for Fall 2013. Person responsible: Committee Deadline: Spring and Fall 2013

Item # 6:	New Business - DOT physical information for CE Trucker Driver's School – all that should be provided to ACC is the Medical Examiner's Certificate * HIPAA release signed by Health Sciences students – does that allow EHS to
Presenter	Renee Cornett
Discussion	Discussion: HIPAA Law Alert, Legal developments affecting HIPAA and medical privacy, A publication of Nixon Peabody LLP, Dated July 21, 2011.  Renee Cornett explained the copy of the handout: HIPAA Law Alert, Legal developments affecting HIPAA and medical privacy. The July 21, 2011 publication reviewed the Texas House Bill 300 signed by Governor Rick Perry  Ms. Cornett then discussed the bill. This bill states that covered entities must maintain training attendance records for all employees. ACC currently maintains training for all of Health Sciences, students, faculty and staff so ACC is already in compliance that aspect of the law.  The law also requires covered entities to provide patients with electronic copies of their EHR within fifteen days of the patient's written request for the records;" at present Dental Hygiene has a 30 day wait.  Ms. Cornett reviewed the Dental Hygiene policy for patient records. Stated that the students learn how to maintain patient records both manually and electronically. By 2014 all records will go electronic and her students will be prepared.  There was discussion about the use of encryption or other methods to ensure that any record being sent via email sent is in compliance with the law to protect- this discussion was focused on dental hygiene and massage therapy (ACC's two covered entities. Ross Greves will explore how to best provide for privacy for these records when transmitted electronically.  Mr. Hill discussed a "third holding party" for medical records. This third holding party would have a secure web site to receive and send medical documents or allow each party to have access to the medical records with a secure access code. Decisions/Actions:  Dental Hygiene will change the policy of providing patients with electronic copies of their EHR from 30 day to 15 days. This will also need to be followed by Massage Therapy.  Mr. Ross & Mr. Hill will review the Dental Hygiene transfer of medical records and make suggestions to improve the current procedures. Recommendations would also be applicable to massage therapy. Follow-up Items  Review transferring and receiving medical records by the Dental Hygiene Department and make recommendations. Person responsible: Ross Greves & Mike Hill Deadline: Next meeting  Link the HIPAA information to the Texas HIPAA Laws to ACC HIPAA information Person Responsible: Pat Recek Deadline: Next Meeting Agenda item: IV. New Business Presenter: Patricia Recek Discussion: HIPAA release -does that allow EHS to receive results from ProMed/Concentra  Clarification: the agenda listed the discussion as related to students, but Becky Cole explained that the issue was related to faculty. Currently, EHS forwards authorization to faculty to get required immunizations, testing (drug) to enable faculty to go to ProMed or Concentra.  These facilities will not release the information to the faculty because the college paying for the immunization/test.  EHS does not need the results of the testing in order to approve payment. There was a discussion of type of test, results of test, and who receives the results of tests. Concerns have been expressed by programs because faculty are not able to the get the test results but there is a delay of those being transmitted to EHS. Come clinical sites will not allow the faculty in the clinical site until they have verification.  Some concern expressed by E. Klein related the possibility of falsification of documentation if the results are given directly to faculty; discussion also followed that most immunization/test results are accepted when provided by faculty.  Discussion of records management with access by certain parties to receive the information. Ms. Richter suggested the HIPAA chair speak with Tony Martinez, from the EMSP program, about his knowledge with the immunization tracking system of the Department of State Health Services and report back to the committee as one example of keeping track of individual health records. Decisions/Actions: * Ms. Recek will speak with Mr. Martinez concerning the Department of State Health Services and report back to the committee on their practices and if it would be something we might incorporate. * The committee approved a HIPAA student release form for Becky Cole to receive the documentation for the student/staff and the release of a copy of the document to the student/staff being tested, who would in turn submit the document to their department or supervisor. Follow-up Items: Copy of release form to be reviewed by committee by email then in turn submit comments. Person responsible: Becky Cole Deadline: When available

Item # 7:	New Business
Presenter	Pat Recek
Discussion	Discussion: Does EHS need HIPAA declaration due to the potential of receiving student health related information as part of the Student Accident process. Decisions/Actions: Becky Cole stated that the ACC attorney had indicated that the student accident information does not fall under HIPAA but that he needed to verify. Follow-up Items- Current system of getting a HIPAA release with the Accident policy will remain unchanged until further clarification. Person Responsible: Becky Cole Deadline: Next Meeting

Item # 8:	New Business
Presenter	Pat Recek
Discussion	Discussion: Respirator physicals for both employees and student Discussed the departments that require a respirator physical. Discussed why the physical is needed and the required length of time the documentations is to be held. Example: Crockett Auto Body repair class. These records are currently kept by EHS. Decisions/Actions: Ms. Cole will look into the possibility to maintain the records in Fortus. Follow-up Items: Look into the possibility of maintaining the records for the respiratory physical to be housed in Fortus. Person Responsible: Becky Cole Deadline: Next Meeting

Item # 9:	HIPAA Events
Presenter	Pat Recek
Discussion	Discussion: Scott & White  A patient contacted ACC stating that an ACC student had accessed her records as an employee of Scott & White and had used that information on Facebook. P. Recek spoke with the patient and gathered data on the student. o The patient's records had been accessed without authorization and used; however the person did it in the role of an employee. Scott and White took action against the employee. o The employee was as student at ACC but was not currently enrolled in any Health sciences program and did not access to the records in her role as a student.  Questions were discussed concerning Continuing Education students who need volunteer hours and who go to facilities to receive the hours needed for class/training. o The facility in which they were doing volunteer work with ensure HIPAA training and compliance, not ACC.  Education Affiliation Agreements were discussed and the procedures for facilities and students and HIPAA procedures.  Questions concerning the declaration of General Studies or Health Science studies in applying to an ACC program were brought up by Mr. Wiegand and if it was related the taking the HIPAA training. Decisions/Actions:  No action needed by ACC. Dental Hygiene Discussion: Student left a patient chart in the operatory file holder and an account summary was left in the operatory file holder that belonged to a separate folder. Program followed published policies and cited the student for "professional error." Follow-up Items  Require student to complete HIPAA training again. Person responsible: Kelly Murphree Deadline: Immediately Agenda Item: V. HIPAA Events Discussion: EVC Copy Machine  Documents found in 9209 (copy room) were brought to Ms. Recek's attention. The documents contained PHI.  Information on the documents were specific to medication orders. Dr. Espinosa (Dept. Chair for Allied Health) and Lisa McCartney, (Dept. Chair for Pharmacy Tech) were asked to review and determine might be used by their faculty. Both indicated that they were not used by their programs.  Ms. Recek's concern was who/where did the information come from and how it was being used.  Discussed location of copy room, and possibility of identifying the person who made the copies either by codes entered into the machine or by campus cameras locating person at the machine at the time the copies were made. Follow-up Items: Ask departments chairs at DC meeting if they have knowledge of these being used by their program. Person responsible: Pat Recek Deadline: Friday, Nov. 16. Discussion: Copy/Fax machines in CE at HBC Additional discussion arose related to the unsecured location of copy and fax machines for Health Science Student/Staff information for continuing education information at Highland Business Center. Decisions/Actions: Dr. Klein will review the current locations of the fax machines at Highland Business Center for receiving and sending the Health Science documents. She will make recommendations to make sure all health sciences information is secure in transmitting or receiving. Follow-up Items  Review and secure fax machine for Health Science information at Continuing Education Highland Business Center. Person responsible: Eileen Klein Deadline:

Item # 10:	Miscellaneous
Presenter	Pat Recek
Discussion	Note: The following are changes in the committee members: Elizabeth Coccia is stepping into Lynn Beaman position on the committee Azure Brown is replacing Mary Ann Bridges on the committee-Ms. Bridges no longer employed at ACC. Alex Matthews is replacing Doug Mitchell on the committee Mike Hill was a substitute for Theresa Harkins Lillian Ha is the new student government representative from Health Sciences Marilee Shopland is the new representative from APTE-Prof-Tech Association. Guests: Jerald Lewis, EMSP Student Tobin Wiegand, ACC-CEA Classified Association, President Handouts: 1. February 23, 2012 meeting minutes 2. HIPAA Law Alert: July 21, 2011 New Texas Health Care privacy law more stringent than HIPAA by Linn Freedman and Christopher Browning, a publication of Nixon Peabody LLP

Item # 11:	Next Meeting Date
Presenter	Pat Recek
Discussion	February 21, 2012 11:30 a.m. - 1:30 p.m. EVC, Bldg. 8000, Third Floor, Room 8358

Austin Community College
5930 Middle Fiskville Rd.
Austin, Texas 78752-4390
512.223.4ACC (4222)