HIPAA and Privacy Act Training -JKO

A Privacy Impact Assessment (PIA) is an analysis of how information is handled:

Physical measures, including policies and procedures that are used to protect electronic information systems and related buildings and equipment, from natural and environmental hazards, and unauthorized intrusion (correct)

physical safeguard in the form of an access control to a secure area of the Valley Forge MTF.

Pursuant to the HIPAA Security Rule, covered entities must maintain secure access (for example, facility door locks) in areas where PHI is located. Allowing an unidentified individual to bypass a security entrance in this scenario violates the HIPAA Security Rule and exposes the MTF and its patients to a potential breach situation.

Privacy Overlay

The Privacy Overlay is the authoritative source of HIPAA Security Rule-specific security controls for DoD and includes supporting guidance to complement overall system security. It is intended to help information systems security engineers, authorizing officials, and privacy officials select reasonable and appropriate protections for ePHI that satisfy current policy requirements.

ePHI

ePHI is PHI that is created, received, maintained, or transmitted in electronic media by a HIPAA CE or BA.

When must a breach be reported to the U.S. Computer Emergency Readiness Team?

Within 1 hour of discovery

Physical safeguards are:

-Administrative actions, and policies and procedures that are used to manage the selection, development, implementation and maintenance of security measures to protect electronic PHI (ePHI). These safeguards also outline how to manage the conduct of the workforce in relation to the protection of ePHI Challenge exam: -Physical measures, including policies and procedures that are used to protect electronic information systems and related buildings and equipment, from natural and environmental hazards, and unauthorized intrusion

Which HHS Office is charged with protecting an individual patient's health information privacy and security through the enforcement of HIPAA?

-Office of Medicare Hearings and Appeals (OMHA) (CORRECT) Challenge exam: -Office for Civil Rights (OCR)

In which of the following circumstances must an individual be given the opportunity to agree or object to the use and disclosure of their PHI?

A and C (answer) a). Before their information is included in a facility directory b). Before PHI directly relevant to a person's involvement with the individual's care or payment of health care is shared with that person

Administrative safeguards are:

A. Administrative actions, and policies and procedures that are used to manage the selection, development, implementation and maintenance of security measures to protect electronic PHI (ePHI). These safeguards also outline how to manage the conduct of the workforce in relation to the protection of ePHI

A Privacy Impact Assessment (PIA) is an analysis of how information is handled:

All of the above To ensure handling conforms to applicable legal, regulatory, and policy requirements regarding privacy To determine the risks and effects of collecting, maintaining and disseminating information in identifiable form in an electronic information system To examine and evaluate protections and alternative processes for handling information to mitigate potential privacy risks

The minimum necessary standard:

All of the above (ANSWER) Limits uses, disclosures, and requests for PHI to the minimum necessary amount of PHI needed to carry out the intended purposes of the use or disclosure Does not apply to exchanges between providers treating a patient Does not apply to uses or disclosures made to the individual or pursuant to the individual's authorization

Which of the following are fundamental objectives of information security?

All of the above (answer) Confidentiality Integrity Availability

What of the following are categories for punishing violations of federal health care laws?

All of the above (answer) Criminal penalties Civil money penalties Sanctions

If an individual believes that a DoD covered entity (CE) is not complying with HIPAA, he or she may file a complaint with the:

All of the above (answer) DHA Privacy Office HHS Secretary MTF HIPAA Privacy Officer

An incidental use or disclosure is not a violation of the HIPAA Privacy Rule if the covered entity (CE) has:

All of the above (answer) Implemented the minimum necessary standard Established appropriate administrative safeguards Established appropriate physical and technical safeguards

The HIPAA Security Rule applies to which of the following:

C. PHI transmitted electronically

Select the best answer. Which of the following are fundamental objectives of information security?

Confidentiality B. Integrity C. Availability D. All of the above

Elements of a risk analysis include:

Defining the scope of the analysis to include all ePHI the CE creates, receives, maintains and transmits, and documenting where the ePHI is located Identifying and documenting reasonably anticipated and potential threats specific to the CE's operating environment and vulnerabilities which, if exploited by a threat, would create a risk of an inappropriate use or disclosure of ePHI Assessing existing security measures Determining and documenting the potential impact and risk to the confidentiality, integrity and availability of ePHI Periodically reviewing and updating the risk analysis

A breach as defined by the DoD is broader than a HIPAA breach (or breach defined by HHS).

True

Which of the following are common causes of breaches?

All of the above (answer) Theft and intentional unauthorized access to PHI and personally identifiable information (PII) Human error (e.g. misdirected communication containing PHI or PII) Lost or stolen electronic media devices or paper records containing PHI or PII

Which of the following statements about the Privacy Act are true?

All of the above (answer) a). Balances the privacy rights of individuals with the Government's need to collect and maintain information b). Regulates how federal agencies solicit and collect personally identifiable information (PII) c). Sets forth requirements for the maintenance, use, and disclosure of PII

Which of the following statements about the HIPAA Security Rule are true?

All of the above (answer) a). Established a national set of standards for the protection of PHI that is created, received, maintained, or transmitted in electronic media by a HIPAA covered entity (CE) or business associate (BA) b). Protects electronic PHI (ePHI) c). Addresses three types of safeguards - administrative, technical and physical - that must be in place to secure individuals' ePHI

Which of the following are breach prevention best practices?

All of this above (answer) Access only the minimum amount of PHI/personally identifiable information (PII) necessary Logoff or lock your workstation when it is unattended Promptly retrieve documents containing PHI/PHI from the printer

Which of the following would be considered PHI?

An individual's first and last name and the medical diagnosis in a physician's progress report

Fundamental objectives of information security:

Confidentiality ## Integrity ## Availability

Technical safeguards are:

Information technology and the associated policies and procedures that are used to protect and control access to ePHI

Information security:

the process of protecting data from unauthorized access, destruction, modification, or disruption

A covered entity (CE) must have an established complaint process.

True

Under the Privacy Act, individuals have the right to request amendments of their records contained in a system of records.

True

The e-Government Act promotes the use of electronic government services by the public and improves the use of information technology in the government.

True (CORECT)