Law Chapter 10 Final Review
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What is the purpose of the implementation specifications of the HIPAA security rule?

instruction for implementation of standards

One of the four general requirements a covered entity must adhere to for compliance with the HIPAA security rule is to ensure the confidentiality, integrity and ___________ of ePHI.

availability

What are the primary distinctions between the HIPAA Security Rule and the HIPAA Privacy Rule?

The security rule applies to electronic PHI, while the privacy rule applies to all forms of PHI, and the security rule has more comprehensive security requirements.

The HIPAA security rule applies to which of the following covered entities?

<p>All of the above</p> Signup and view all the answers

If a HIPAA security rule implementation specification is addressable, what does this mean?

<p>An alternative may be implemented.</p> Signup and view all the answers

The HIPAA 'Security Awareness and Training' administrative safeguard requires all of the following addressable implementation programs for an entity's workforce except:

<p>Disaster recovery plan</p> Signup and view all the answers

The Security Officer holds a required full-time position under the HIPAA security rule.

<p>False</p> Signup and view all the answers

What can non-compliance with the HIPAA security rule lead to?

<p>Both civil penalties and criminal penalties.</p> Signup and view all the answers

Privacy and security training should be separated.

<p>True</p> Signup and view all the answers

What term is also used to denote the HIPAA requirement of Contingency Planning?

<p>Emergency mode of operation.</p> Signup and view all the answers

Copying data onto tapes and storing the tapes at a distant location is an example of what?

<p>Data backup.</p> Signup and view all the answers

The capture of data by a hospital's data security system that shows multiple invalid attempts to access the patients' database is an example of what type of security control?

<p>Audit trail.</p> Signup and view all the answers

The HIPAA security rule contains safeguards for reliability.

<p>False</p> Signup and view all the answers

The enforcement agency for the security rule is?

<p>Office for Civil Rights.</p> Signup and view all the answers

What does the HIPAA security rule require that the covered entity do?

<p>Protect ePHI from reasonably anticipated threats.</p> Signup and view all the answers

What factors does the HIPAA Security Rule consider for flexibility in implementation based on reasonableness and appropriateness?

<p>All of the above</p> Signup and view all the answers

With addressable standards, the covered entity may do all but which of the following?

<p>Ignore the standard since it is addressable</p> Signup and view all the answers

The HIPAA security rule requires that passwords?

<p>Be updated by organizational policy.</p> Signup and view all the answers

According to the HIPAA Security Rule, what should a covered entity instruct a physician who needs a new smartphone and her current smartphone contains ePHI?

<p>Turn in her old smartphone.</p> Signup and view all the answers

What should the hospital policy include for a nurse administrator called in emergency situations who does not typically take call?

<p>A provision to allow her emergency access to the system.</p> Signup and view all the answers

The HIPAA security rule contains what provision about encryption?

<p>It is required based on organizational policy.</p> Signup and view all the answers

What provision of the HIPAA security rule was violated when the admissions director installed new computers without IT's approval?

<p>Device and media controls.</p> Signup and view all the answers

What security issue should be included in the risk analysis when considering sending medical transcriptionists home to work?

<p>Access of data by unauthorized persons.</p> Signup and view all the answers

What should home health nurses at a covered entity receive guidance about to avoid HIPAA violations?

<p>Need additional training as remote workers.</p> Signup and view all the answers

Some of the best steps that workers can take to comply with the HIPAA security rule include ensuring?

<p>The security of mobile devices.</p> Signup and view all the answers

What do the latest provisions to HIPAA include?

<p>Breach notification, enforcement, and modifications to the privacy and security rules.</p> Signup and view all the answers

Which of the following would provide the best support of an organization's efforts toward compliance with the security rule?

<p>Building security into software and systems</p> Signup and view all the answers

What does the HIPAA security rule allow flexibility in implementation based on?

<p>Organizational assessment.</p> Signup and view all the answers

Which term does the security rule use to define data or information that has not been altered or destroyed in an unauthorized manner?

<p>Integrity.</p> Signup and view all the answers

The security rule's five sections include encryption requirements.

<p>False</p> Signup and view all the answers

When developing security procedures for a remote workforce, which documents should the HIM director reference?

<p>Privacy and security rules, state statutes, and other federal statutes.</p> Signup and view all the answers

What policy has the hospital likely not complied with regarding Dr. Watson, who frequently requests others' passwords?

<p>Sanction policy.</p> Signup and view all the answers

Security awareness training programs should include?

<p>Periodic security reminders.</p> Signup and view all the answers

All of the following are security rule physical safeguard standards except:

<p>Contingency planning</p> Signup and view all the answers

Which of the following is a best practice to comply with the revised security provisions of the HITECH Act?

<p>Inventory BAs to determine which Business Associates Agreements need to be amended</p> Signup and view all the answers

Which portion of a security program would ensure that ePHI is not stored on recycled equipment?

<p>Device and media controls.</p> Signup and view all the answers

In general, when should reviews for compliance with various aspects of the security rule be conducted?

<p>Periodically.</p> Signup and view all the answers

Disabling the USB drive on a computer is an example of what type of security?

<p>Workstation.</p> Signup and view all the answers

What violation occurs when laptop computers used for projects involving ePHI are immediately recirculated to another user?

<p>Device and media controls.</p> Signup and view all the answers

One of the four general requirements a covered entity must adhere to for compliance with the HIPAA security rule is to ensure the confidentiality, ________, and availability of ePHI.

<p>integrity</p> Signup and view all the answers

When should access to the electronic health record system be terminated for an employee who resigns?

<p>Promptly upon resignation.</p> Signup and view all the answers

A subcontractor of a business associate may?

<p>Transmit ePHI on the business associate's behalf if it provides satisfactory assurances that the information will be appropriately safeguarded.</p> Signup and view all the answers

Assessing HIPAA training programs is important for which of the following reasons?

<p>Both A and B</p> Signup and view all the answers

The best source for obtaining primary information on addressing the HIPAA Security Rule would be which of the following sources?

<p>Department of HHS</p> Signup and view all the answers

When external reviewers request access to electronic patient records, how should IT professionals handle this?

<p>Suggest records necessary for audit be placed in a queue.</p> Signup and view all the answers

Which of the following best describes the role that the HIIM professional should play in HIPAA security compliance?

<p>Moderate involvement since the rule is very operational.</p> Signup and view all the answers

To ensure compliance with the HIPAA security rule training requirement, the HIIM Director should do which of the following?

<p>Determine special needs of HIM staff and provide training.</p> Signup and view all the answers

What does the workforce security administrative safeguard require?

<p>Both ensure appropriate ePHI access by workforce members and prevent access to ePHI by workforce members who should not have access.</p> Signup and view all the answers

What is the purpose of the implementation specifications of the HIPAA security rule?

<p>Instruction for implementation of standards.</p> Signup and view all the answers

Study Notes

HIPAA Security Rule Overview

  • Implementation specifications provide guidance for executing the standards set by HIPAA.
  • Covered entities must ensure confidentiality, integrity, and availability of electronic Protected Health Information (ePHI).

Distinctions Between Security and Privacy Rules

  • The Security Rule covers only electronic PHI while the Privacy Rule encompasses all forms (electronic, written, oral).
  • Security Rule includes comprehensive requirements for safeguarding electronic data that are more detailed than those in the Privacy Rule.

Scope of HIPAA Security Rule

  • Applies to various covered entities including hospitals, electronic billing companies, and health insurance plans.
  • Non-compliance can result in civil and criminal penalties.

Requirements and Specifications

  • Addressable implementation specifications allow entities to adopt alternatives as needed, rather than strictly following the rule.
  • Security awareness training is mandatory, covering regular reminders but excluding disaster recovery plans.

Role of Security Officer

  • The Security Officer does not need to hold a full-time position as mandated by HIPAA.
  • Responsibilities include ensuring training and compliance related to ePHI security.

Risk Management and Compliance

  • Important to protect ePHI from anticipated threats, assessing needs based on the entity's size, capabilities, and cost of measures.
  • Passwords should be updated according to organizational policy to maintain security.

Training and Awareness

  • HIPAA training must be comprehensive and integrated, not separated by topics like privacy and security.
  • Remote workers need additional training to comply with HIPAA, highlighting the importance of ongoing education.

Data Backup and Security Controls

  • Data backup involves storing information safely, ensuring recoverability.
  • Audit trails help track unauthorized access attempts to protect data integrity.

Encryption and Device Controls

  • Encryption requirements depend on the organization’s policy, ensuring ePHI is safeguarded.
  • Device and media controls are critical, requiring checks before transferring equipment to prevent mishandling of ePHI.

Incident Response and Access Management

  • Timely termination of access to ePHI upon employee resignation is vital.
  • Protocols should allow emergency access to systems while maintaining HIPAA compliance.

Business Associates Agreement (BAA)

  • Subcontractors can transmit ePHI under a BAA if they assure appropriate safeguards are in place.
  • Regular audits and reviews are necessary for compliance and assessing training effectiveness.

Compliance Best Practices

  • Building security into software and systems enhances compliance with the HIPAA Security Rule.
  • Training staff on identifying security risks, particularly with mobile devices, is crucial for safeguarding ePHI.

Conclusion and Key Notes

  • Regular risk assessments should be conducted to stay in line with HIPAA Security Rule requirements.
  • HIIM professionals play a moderate role in HIPAA compliance, focusing on both administrative and operational aspects of data security.

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Prepare for your final exam with this comprehensive review of Law Chapter 10. This quiz covers key concepts related to the HIPAA security rule, including the implementation specifications and requirements for compliance. Test your understanding of critical terms and definitions necessary for legal proficiency.

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