Committee Meetings and Minutes

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HIPAA Task Force Committee

Meeting Minutes

Current Status of Minutes: Final
Date	October 9, 2014
Time	11:30 AM - 1:00 PM
Location	EVC, Bldg. 8000, Room 8358

Members Present
Susan Corbett, Renee Cornett, Security Officer, Carolyn de Cordova, Rudolph (Rudy) Garza, Ross Greves, Nancy Jenkins, Mary Keeton, Emilie Kunze, Michelle Landrum, Ginger Locke-Floyd, Jose Milan, Patricia Recek, Marilyn Rehm-Skewis, Support Staff, Robyn Richter, Nancy Walters, Nancy Walters, Privacy Officer, Nocomus (Noko) Wilson
Guests Present
James (Mitch) Pope

Item # 1:	Approval of Agenda
Presenter	Pat Recek
Discussion	Discussion: *A request was made from Pat Recek for additions to the agenda. With no additions Pat Recek requested a motion to approve the agenda. Mary Keeton made the motion to approve the agenda, Renee Cornet second, all approved, none opposed Decision/Actions: Agenda approved by committee Follow-up Items >None

Item # 2:	2. Approval of November 7, 2013 Minutes
Presenter	Pat Recek
Discussion	Discussion: *The overhead projector was used to view the Committee Meetings and Minutes Repository web site: http://www3.austincc.edu/it/meetingminutes/. A handout was passed around for new members to review the November 7, minutes. Pat Recek requested a discussion of the minutes. With no discussion, Ms. Recek asked for a motion for approval of the minutes. Robyn Richter made a motion to approve the minutes, Renee Cornett second, all approved, none opposed. Decisions/Actions: Minutes for the November 7, 2013 meeting approved by Committee Follow-up Items: None

Item # 3:	3. Introduction of new members and overview of role of HIPAA committee and members.
Presenter	Pat Recek
Discussion	Discussion: Pat Recek welcomed all members to the meeting. Each member was asked to introduce themselves to everyone by giving their name and their department. New members were encouraged to review the ACC HIPAA web sites. As the Components Organizational Guidelines was displayed on the overhead, Pat briefly discussed the Business Associate, Non-Business Associate and covered Entitles for the new members. Pat Recek discussed the HIPAA Training and the importance of maintaining records on all students and staff members. The following web sites were linked on the overhead with a brief description http://www.austincc.edu/hipaa/index.php Health Insurance Portability and Accountability Act of 1996 (HIPAA) http://www.austincc.edu/hipaa/training.php HIPAA Training http://www.austincc.edu/hipaa/Intro.php HIPAA Introduction & Components http://www.austincc.edu/hipaa/orgchart.php Components Organizational Guidelines Decisions/Actions: Committee Members: To review HIPAA at Austin Community College web sites before the next meeting.

Item # 4:	4. Old Business – Compliance Review Cycle Spring and Fall 2014; spring 2015- update of review/Recommendations
Presenter	Pat Recek
Discussion	Discussion: The departments/programs that completed the Spring Compliance Reviews were discussed. Several members announced that they had completed their review and would forward a copy. Those reviews that were not completed in the spring would be posted on the review schedule for Fall and all would need to be completed by the end of the Fall Semester. The importance of the review for each of the departments and the importance of keeping training records for students, faculty and staff. The Compliance Review was briefly discussed: how to contact a Program/Department, going over the paperwork, and writing up the review, sending in the report to Pat Recek The major actions taken by the Office of Civil Rights when being reviewed has been the lack of HIPAA training records. * An area of development was expressed for maintaining records with the HIPAA signed Confidentiality Certificate that is presented after the training. How to house the certification, how long to house the certification and what to do with records when students have graduated, or faculty/staff are no longer employed. *The number of years required for HIPAA, Department's Accreditation, and ACC regulations to house records. Decisions/Actions: All unreported Spring Compliance Reviews would be posted for completion on the Fall Schedule. Fall Schedule to be sent out with unreported Spring Compliance Reviews listed. List of Department Chair would be sent to members to contact when starting their reviews. Follow-up Items 1. Send out new schedule for Compliance Review Person responsible: Pat Recek Deadline: As soon as possible 2. Send Report for Sonography Person responsible: Robin Richter 3. Send in Report for Pharmacy Person responsible: Ginger Locke-Floyd

Item # 5:	5. New Business - HIPAA Compliance-Fax/Copy Machines
Presenter	Pat Recek
Discussion	Discussion: Identified several areas within Health Sciences and Continuing Education where fax machines are located and are open to the public and are not HIPAA or FERPA compliant. Receiving faxed information with HIPAA or FERPA information from health facility to a fax machine that is unattended and/or open to public use. Identifying stationary or request forms provided by ACC that list a fax number but the number is not a secure fax location. Moving fax machines to a secure location. Password protected fax machines. Copy Machines new and old. Contract that requires the machine to be cleared of stored information before the equipment is assigned a new facility. Use of unauthorized personal copy or fax machines. Additional information technology tools in use at ACC for detecting PHI at risk. Request additional information on sharing patient records with another health facility/or they with ACC Health Science Covered Entities. Discussed Google Doc and Virtually Private Networks, Internal Servers for sharing patient or student records. Containers for disposal of documents– Locked Shredded and Recycled Contract Service Bin/s for Classified Information or just a Paper Recycled Bin. Decisions/Actions: Post a sign on Fax/Copy Machine to return all items that were picked up by mistake. Contact Round Rock Campus Manager to review recycled bin or if they need a secure shredded disposal service for departments. Review stationary/request forms that provide a fax number: 1. Remove fax number 2. Revise fax number with a message that the "fax number is not secure for PHI" 3. Replace fax number with a secure fax number (Health Sciences 512-223-5901 Dean's Office) Follow-up Items Discuss with Health Science Department Chair to review stationary or forms for unsecure fax numbers. Check for non ACC (personal) copy/fax machines. Identify recycling at Round Rock Health Sciences Review the Fax Machine locations and/or password protection with Continuing Education/Health Professions Institute. Person responsible: Pat Recek Deadline: TBA Review fax and copy machines that post the number on the printed item (fax or copy machine sent from) Person responsible: Mitch Pope Deadline: TBA Send Pat Recek an email with information on Round Rock for reviewing the Recycled Bins in the Health Science Area for consideration of a Secure Shredded Document Service. Person responsible: Carolyn De Cordova Deadline: As soon as possible.

Item # 6:	5. New Business-Update to Website New Health Science PowerPoint
Presenter	Pat Recek
Discussion	Discussion: Overview of HIPAA Training Module. The training was designed by Seton & St. David's and used by ACC with permission to add specific information that addresses ACC needs. Two new slides were added by Seton to comply with the Texas House Bill 300 training. A brief overview of the bill was given as a Bill signed in 2011 by Governor Rick Perry, effective September 1, 2012 which is in addition to HIPAA. Pat requested that the members review the Bill. Students who had previously taken the HIPAA training were not asked to retake the revised training. *Students HIPAA Training does not transfer after graduation. Decisions/Actions: Additional questions relating to the Texas House Bill 300 will be added to the HIPAA training module. Follow-up Items Add to HIPAA Training with information relating to the Texas House Bill 300 Person responsible: Pat Recek New lab Manager Deadline: TBA

Item # 7:	6. HIPAA Events – Overview and Recommendations Vocational Nursing / Surgical Technology
Presenter	Pat Recek
Discussion	Discussion: Vocational Nursing student left notebook in hospital cafeteria. The notebook was found by the director of nursing and the notebook contained room number and notes. Progressive discipline policy followed by program and student had to redo HIPAA training. Surgical Technology student took a picture with her phone in a clinical setting. More than one person was able to be identified in the picture. The student sent the instructor the picture. All violation forms were sent to the clinical facility including the picture. The picture was taken before the student withdrew from the program but sent after student withdrew. The facility privacy officer is review the case and will make a decision to report to the Office of Civil Rights or to retain at the facility. Decisions/Actions: No action by the Committee for either the VNG or the Surgical Technology student. Review with Department Chair information on cell phones in a clinical setting to make sure it is posted in their handbooks. Follow-up Items: Review Cell Phones in a clinical setting with Department Chair at the next meeting Person responsible: Pat Recek Deadline: TBA

Item # 8:	7. Miscellaneous
Presenter	Pat Recek
Discussion	Discussion: *Renee Cornett announced that the Dental Hygiene Program has advanced into digital imaging. Renee Cornett requested input from the committee on transmitting digital x-rays/images to other facilities for the treatment of patients or receiving digital x-rays/images from facilities for the treatment of patients. Mitch Pope and Ross Greves discussed electronic permission, electronic encryption and drop boxes and how they work. Mitch Pope discussed how emails are secured, commercial accounts such as Eagle South and the pros and cons of time limits. He suggested looking into Eagle South or checking with ACC IT to set up a drop box. Further discussion continued on facilities sending PHI and permission forms and permission forms content. Decisions/Actions: Renee Cornett will check with ACC IT department for information on securing a drop box.

Item # 9:	8. Announcements
Presenter	Pat Recek
Discussion	Discussion: Next Meeting will be in the month of February or March. Committee members should look for an email with suggested meeting dates.

Item # 10:	Next Meeting Date:
Presenter	Pat Recek
Discussion	TBA Time: TBA Location: EVC, Bldg. 8000, Third Floor, Room 8358

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