CHPC Privacy Program Management Questions and Answers — Questions and Answers
Question 1: A healthcare organization is conducting its annual HIPAA Security Rule risk analysis. Which of the following is the PRIMARY objective of this process?
- To eliminate all possible threats to electronic protected health information (ePHI).
- To identify and implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level. (Correct answer)
- To satisfy the Meaningful Use core objective for protecting electronic health information.
- To purchase a certified Electronic Health Record (EHR) technology.
Correct answer: To identify and implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level.
The primary goal of a HIPAA Security Rule risk analysis is not to eliminate all risks, which is impossible, but to identify potential risks and vulnerabilities and implement security measures to reduce those risks to a reasonable and appropriate level for the organization's specific environment.
Question 2: As part of managing a privacy program, the Privacy Officer is responsible for developing and implementing policies and procedures. According to the HIPAA Privacy Rule, which of the following areas requires a specific policy that identifies which workforce members need access to PHI to carry out their duties?
- Patient's right to request an amendment of their PHI.
- The process for reporting a breach to the media.
- The 'Minimum Necessary' standard for internal access and use. (Correct answer)
- The technical specifications for encrypting data at rest.
Correct answer: The 'Minimum Necessary' standard for internal access and use.
The HIPAA Privacy Rule's 'Minimum Necessary' standard requires a covered entity to develop policies and procedures that identify the persons or classes of persons who need access to PHI, the categories of PHI they need, and any conditions appropriate to such access to perform their jobs.
Question 3: A hospital's Privacy Officer receives a verbal complaint from a patient who believes their PHI was impermissibly shared. What is the most appropriate FIRST step the Privacy Officer or their designee should take in handling this complaint?
- Immediately report the potential breach to the Office for Civil Rights (OCR).
- Offer the patient a financial settlement to resolve the issue quickly.
- Discipline the employee accused of the impermissible sharing.
- Ask the patient to submit the complaint in writing and begin an internal investigation. (Correct answer)
Correct answer: Ask the patient to submit the complaint in writing and begin an internal investigation.
Standard procedure for handling patient complaints is to take them seriously, document them, and conduct a thorough internal investigation. It is a best practice to ask the patient to submit the complaint in writing to ensure clarity and proper documentation before taking further action like reporting or disciplinary measures.
Question 4: Which of the following is a critical, non-technical component of an effective privacy training and awareness program within a healthcare organization?
- Implementing multi-factor authentication for all systems containing ePHI.
- Establishing a sanction policy for workforce members who fail to comply with privacy policies. (Correct answer)
- Conducting annual penetration testing of the organization's network.
- Deploying an intrusion detection system to monitor for malicious activity.
Correct answer: Establishing a sanction policy for workforce members who fail to comply with privacy policies.
While technical safeguards are vital, an effective privacy program must also include administrative components. A sanction policy is a required administrative safeguard under HIPAA that establishes consequences for non-compliance, reinforcing the importance of training and adherence to privacy policies among the workforce.
Question 5: A Privacy Officer is tasked with ensuring their organization's audit controls are compliant with the HIPAA Security Rule. Which of the following best describes the function of 'audit controls' in this context?
- Preventing unauthorized physical access to facilities where ePHI is stored.
- Implementing mechanisms to record and examine activity in information systems that contain or use ePHI. (Correct answer)
- Assigning a unique name or number for identifying and tracking user identity.
- The formal, external review of financial records by a certified public accountant.
Correct answer: Implementing mechanisms to record and examine activity in information systems that contain or use ePHI.
The HIPAA Security Rule requires covered entities to implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems containing ePHI. These are known as audit controls and are crucial for detecting and responding to security incidents.
Question 6: When developing a comprehensive privacy program, a Privacy Officer must create numerous policies and procedures. For which of the following documents must the organization retain a copy for at least six years from the date of its creation or the date when it last was in effect, whichever is later?
- Individual employee training completion certificates for a single year.
- A patient's signed authorization for a one-time disclosure of PHI.
- The organization's Notice of Privacy Practices. (Correct answer)
- Monthly reports from the network intrusion detection system.
Correct answer: The organization's Notice of Privacy Practices.
HIPAA requires that covered entities retain required documentation, which includes its policies and procedures like the Notice of Privacy Practices, for a minimum of six years from the date of creation or the date it was last in effect, whichever is later.
CHPC Privacy Program Management Questions and Answers
A healthcare organization is conducting its annual HIPAA Security Rule risk analysis.
Which of the following is the PRIMARY objective of this process?