HIPAA Security Training – Day 1 HIPAA Security Rule
HIPAA Security Rule Part 1
- Threats: General review of threats (real and perceived) prompting Congress to include security requirements in the HIPAA Administrative Simplification Title.
- Definition and Terminology: Review of general definitions of security and specifically how those definitions apply to the rule and what data must be protected by the implementation of appropriate security measures.
- Security Services
- Security Mechanisms
- Security Rules: Detailed review of the security rule, components of the security rule, and specific requirements (including a reference back to security requirements referenced in the HIPAA Privacy Rule).
- Categories of Safeguards
- Implementation Specifications
- Approach and Philosophy
- Security Principles
- Administrative Safeguards
- Physical Safeguards
- Technical Safeguards
- Organizational Requirements
- Policies and Procedures, and Documentation Standards
- Administrative Safeguards: Definition of “administrative safeguards” as they relate to security and the rule. A review of required administrative safeguards and their application within a covered entity and business associate.
- Administrative Safeguards
- Security Management Process
- Assigned Security Responsibility
- Workforce Security
- Information Access Management
- Security Awareness and Training
- Security Incident Procedures
- Contingency Plan
- Business Associate Contracts Standard
- Physical Safeguards: Definition of “physical safeguards” as they relate to security and the rule. A review of required physical safeguards and their application within a covered entity and business associate.
- Facility Access Controls
- Workstation Use
- Workstation Security
- Device and Media Controls
- Physical Safeguards Review
HIPAA Security Rule Part 1
- Technical Safeguards (general): Definition of “technical safeguards” as they relate to security and the rule. A review of required technical safeguards and their application within a covered entity and business associate.
- Access Control
- Audit Controls
- Person or Entity Authentication
- Security Compliance process: Risk Analysis, Vulnerability Assessment, Remediation, Contingency Planning, Audit & Evaluation
- Transmission Security
- Technical Safeguards (technical details): A review of required technical safeguards including a more technical review of required or addressable safeguards, implementation, and ongoing maintenance.
- TCP/IP Network Infrastructure
- Firewall Systems
- Virtual Private Networks (VPNs)
- Wireless Transmission Security
- Overview of Windows XP and Vista Security
HIPAA Security Training – Day 2 Security, Enforcement Rule & ARRA 2009
HIPAA Security Rule Part 2
- Digital Signatures & Certificates: A review of the use of higher forms of individual or entity authentication that is quickly becoming a requirement legally and to reduce legal risk.
- Digital Signatures
- Digital Certificates
- Public Key Infrastructure (PKI)
- Solution Alternatives
- Identity theft prevention and HIPAA
- Security Policy: A review of the requirements to document security program practices and processes in policy and related workforce training requirements. Also a review of required policy maintenance and retention.
- Risks, Risk Management and Policy Development/Implementation
- General Security Standards Impact on Policy Development
- Policy Training Requirements
- Security Policy Considerations
- Overview: An overview of the rule and rule requirements including entities and individuals the rule applies to.
- Definitions: A review of rule definitions including (not inclusive) what represents a violation, compliance, definition of agent, resolution processes, and HHS enforcement powers.
- Informal resolution process: A discussion of what an informal resolution is and what it entails. Also, a review of the rule’s emphasis on informal resolution and language allowing such resolution at any phase of a violation investigation, penalty assessment, and appeal.
- Formal resolution process (i.e., penalties, administrative hearings, appeal process, etc.): A discussion of what would likely trigger a formal resolution process, HHS requirements and authority to investigate, rights and responsibilities of covered entities and resulting actions if civil penalties are levied and paid by the covered entity.
- Compliance audits A discussion of the authority to conduct compliance audits, current audit activity, and prospective audit activity.
Identity Theft Protection Laws
A general review of existing identity theft protection laws and breach notification requirements. Includes a specific discussion of California identity theft and medical identity theft protection laws.
American Recovery and Reinvestment Act of 2009 (ARRA), Title XIII
This should be an introduction that will cover general aspects of the incentives and requirements provisions of Title XIII health information technology (HIT). These discussions will also touch on the purpose of security and privacy in HIT investment provisions and the development of standards.
American Recovery and Reinvestment Act of 2009 (ARRA), Title XIII, Subtitle D – HITECH
- Privacy Provision Overview: Overview of the privacy provisions included ARRA and the relationship to the HIPAA Administrative Simplification Title provisions.
- Business Associates – New Requirements: A discussion of business associates’ new requirement to statutorily adhere to the provisions of the HIPAA Administrative Simplification Title Privacy and Security Rules. The discussion includes a review of the timeline for compliance and the implications for business associates.
- National Identity Theft Protection Provisions: A discussion of the requirements of the new identity theft protection provisions, what is considered a breach or inappropriate disclosure, breach notification requirements, and entities/individuals covered. The discussion also includes new reporting requirements by entity/individual, HHS, and the Federal Trade Commission (FTC).
- Marketing Prohibitions and Restrictions: An overview of the enhanced restrictions related to the use and disclosure of PHI where the entity or individual is paid for such use and disclosure and stricter prohibitions against using PHI for marketing purposes.
- Enforcement Provisions: A discussion of the new enforcement provisions, entities/individuals covered, and how such enforcement relates to the HIPAA Enforcement Rule and current compliance audits. The discussion also includes a discussion of changes in penalties and the addition of a newly defined criminal act (formerly a civil violation).
- Reporting Requirements: A discussion of new requirements for the reporting of breaches to HHS and/or the FTC and annual reports relating to compliance, rule violations, breaches, etc. to Congress and the public.
Omnibus Rule of January 2013
- Breach Notification Rule
- New Limits on Uses and Disclosures of PHI
- Business Associates
- Increased Patient Rights
- Notice of Privacy Practices
- Increased Enforcement
If you need additional information for this course or conduct onsite HIPAA Security Training for your employees, contact us at Bob@supremusgroup.com or call (515) 865-4591.