CHP CHP Business Associates & Vendor Management 2 — Questions and Answers
Question 1: Under the HIPAA Security Rule, the primary purpose of a risk analysis is to:
- Evaluate the financial stability of technology vendors
- Identify potential threats and vulnerabilities to the confidentiality, integrity, and availability of ePHI (Correct answer)
- Assess patient satisfaction with electronic health records
- Determine optimal staffing levels for the IT department
Correct answer: Identify potential threats and vulnerabilities to the confidentiality, integrity, and availability of ePHI
A risk analysis identifies potential threats and vulnerabilities to the confidentiality, integrity, and availability of ePHI as required by the HIPAA Security Rule.
Question 2: How often must a covered entity perform a HIPAA Security Rule risk analysis?
- Annually, without exception, per regulatory mandate
- Every 3 years on a fixed schedule
- Periodically and whenever there are significant environmental or operational changes (Correct answer)
- Only at the time of initial HIPAA program implementation
Correct answer: Periodically and whenever there are significant environmental or operational changes
HIPAA requires risk analyses to be conducted periodically and whenever significant changes occur in the environment, operations, or technology.
Question 3: What must follow a completed HIPAA risk analysis?
- Submission of the analysis results to HHS OCR
- Implementation of a risk management plan addressing identified risks (Correct answer)
- Distribution of analysis results to all workforce members
- Archiving the results without further required action
Correct answer: Implementation of a risk management plan addressing identified risks
A risk analysis must be followed by a risk management plan that prioritizes and addresses the identified risks to ePHI.
Question 4: When evaluating a cloud service provider to handle ePHI, which factor is most critical from a HIPAA compliance standpoint?
- The provider's brand recognition and market share
- Whether the provider will sign a BAA and demonstrates HIPAA compliance (Correct answer)
- The provider's pricing model and cost structure
- The geographic location of the provider's headquarters
Correct answer: Whether the provider will sign a BAA and demonstrates HIPAA compliance
Any cloud service provider that handles ePHI must be willing to enter a BAA and demonstrate the ability to comply with HIPAA requirements.
Question 5: How does the HIPAA 'minimum necessary' standard apply to business associates?
- Business associates may use PHI for any purpose related to healthcare delivery
- Business associates must limit PHI access to only what is needed to perform their contracted function (Correct answer)
- Business associates must obtain patient consent before each use of PHI
- Business associates are exempt from the minimum necessary standard under the BAA
Correct answer: Business associates must limit PHI access to only what is needed to perform their contracted function
Business associates must restrict their use and disclosure of PHI to the minimum necessary to fulfill their contracted obligations.
Question 6: A covered entity that shares PHI with a vendor without executing a required BAA is subject to:
- No penalty, provided no breach ultimately occurs
- HIPAA civil monetary penalties and potential corrective action (Correct answer)
- Only an informal written warning from HHS OCR
- State law penalties exclusively, with no federal exposure
Correct answer: HIPAA civil monetary penalties and potential corrective action
Sharing PHI without a required BAA is itself a HIPAA violation exposing the covered entity to civil monetary penalties and OCR corrective action, regardless of whether a breach occurs.
CHP CHP Business Associates & Vendor Management 2
Under the HIPAA Security Rule, the primary purpose of a risk analysis is to: