Temple University Health System

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Temple University Health SystemCorporate Compliance ProgramSTANDARDS OF CONDUCTHIPAA PRIVACY & SECURITYMaribel Valentin, EsquireAssociate CounselCorporate Compliance and Privacy Officer

The TUHS Corporate ComplianceProgram is composed of five elements: Standards of ConductCorporate Compliance and Privacy Officer (CCO)Compliance Hotline (800-910-6721)Compliance InfrastructureContinued Compliance

Corporate Compliance ProgramSTANDARDS OF CONDUCT1. Following the rules TUHS employees will carry outtheir duties in a manner that is compliant with allrelevant laws and regulations, and consistent with bestpractices adopted by TUHS

Corporate Compliance ProgramSTANDARDS OF CONDUCT2. Reporting violations: Each employee has an individualresponsibility for reporting to an appropriate supervisoror senior management or the Compliance Officerany activity by any colleague, physician, subcontractor,vendor or any process that appears to violate applicablelaws, rules, regulations, accreditation standards,standards of medical practice, federal healthcareconditions of participation, or this compliance program.

NO RETALIATIONIt is the stated policy of TUHS that noretaliation will be taken against anyemployee for reporting problems. Reports may be made anonymously,through the Compliance Hotline, or Directly to Maribel Valentin, Esq. AssociateCounsel and CCO at (215) 707-5605.

Corporate Compliance ProgramSTANDARDS OF CONDUCT3. Medical Necessity: All treatment recommended andimplemented at TUHS will be medically necessary;medical necessity is determined by the acceptedprofessional standards of the relevant medicalprofession. Treatment decisions will not be affected bythe patient’s type of insurance or the patient’s ability topay for such services.

Corporate Compliance ProgramSTANDARDS OF CONDUCT4. No Referral Payments: TUHS will not pay any personor entity any form of remuneration for the referral ofpatients nor offer any financial inducement, gift orbribe to any prospective patients to encourage them toundergo treatment at TUHS.

Corporate Compliance ProgramSTANDARDS OF CONDUCT5. Accurate Records: All billing and patient records willbe accurate, complete and as detailed as required bygovernment and professional standards. Each step inthe treatment process, from admission throughdischarge, shall be documented appropriately in thepatient’s medical records. Furthermore, no servicewill be billed unless fully justified by thedocumentation of the medical staff as reflected inpatient medical records.

Corporate Compliance ProgramSTANDARDS OF CONDUCT6. Full Implementation of the Standards of Conduct:The Standards of Conduct apply to all TUHSemployees. To the extent feasible, TUHS willensure that all pertinent provisions of the Standardsof Conduct will be implemented fully for all TUHSmanaged facilities, and bind any independentcontractors, temporary or contract employees.

HIPAAPrivacy & Security Regulations

HIPAA – It’s the Law Federal requirement Privacy- effective since April 14, 2003 Security- effective on April 21, 2005 HITECH- effective February 11, 2009 Requires healthcare organizations to maintainthe privacy and security of Protected HealthInformation (PHI).

HIPAA vs State Law When state law is more restrictive than the federalHIPAA Regulations, then state law prevails, forexample: Pennsylvania has set more restrictions onreleasing certain types of records: HIV/AIDS Drug/Alcohol Mental Health Requires patient authorization prior torelease.

Privacy Rule Covers all Protected Health Information (PHI)

Understanding PHIseehearsay PHI is any and all informationabout a patient’s health thatidentifies the patient, orinformation that could identify thepatient. As a rule of thumb, any patientinformation that you see, hear orsay must be kept confidential.

Understanding PHI cont’d PHI is information that can individually identify a patient. PHI can include: Any type of information found in medical and billingrecords, for example: Diagnoses, Test Results, Progress Notes, etc Name, Address, Phone, Social Security Number,Photographs, Date of Birth, medical record number,billing number, etc

Preventing UnauthorizedDisclosures Do not: Discuss patient information in public areas Position computer screens or leave itunattended so unauthorized persons mayview the private data Leave medical records unattended

HIPAA Patient Privacy “Rights”The Privacy Regulations provide patients with the followingRights: Right to Notice - Right to receive the TUHS Privacy Notice uponregistration that describes how we use and disclose Protected HealthInformation and how to gain access to the information. Right to Access - Right to inspect and/or receive copies of theirmedical record. Right to Amend - Right to request a change in their medicalinformation. Right to an Accounting of Disclosures - Right to request a listing ofcertain disclosures made by the facility of their protected healthinformation

HIPAA Patient Privacy Rights cont’d Right to Request Restrictions - Right to request a limit on the medicalinformation we use or disclose about the patient for treatment, paymentor healthcare operations. Right to Request Confidential Communications - Right to requestthat the hospital communicate with the patient in a certain manner or at aparticular address. Right to File a Complaint - Right to file a complaint with the hospitalPrivacy Officer or with the Secretary of Health and Human Services ifthey feel their privacy rights have been violated. Right to Breach Notification- Right to receive notification of theunauthorized disclosure of Protected Health Information.

HIPAA and the Police Limited exception to HIPAA Under specific circumstances PHI can be givento police without authorization. With a court order, warrant, subpoena or summons If mandated by statute- gunshots, child abuse To correctional facilities for continuity of care If a crime is committed on TUHS premises To locate a suspect or missing person or, If the victim of the crime agrees or if unable to agreeit is determined to be in the victim’s best interest.

How much PHI can we share? All disclosures are subject to a determinationthat PHI disclosed is the MINIMUMNECESSARY for the lawful purpose. The hospital must either know the officialmaking the request or verify their identity andauthority before disclosing PHI.

Security Rule Focuses on Safeguarding electronicProtected Health Information (ePHI)

General Security Requirements Ensure the confidentiality, integrity and availability ofall electronic Protected Health Information (ePHI) Confidentiality: that patient information is not madeavailable or disclosed without proper authorization. Integrity: that patient information has not been altered ordestroyed. Availability: that patient information is accessible andusable upon demand by an authorized person.

Security SafeguardsSecurity Safeguards that must be met include: Administrative - Developing information security programsdesigned to protect ePHI and to also manage the conduct of theworkforce in the relation to the use of the protected information. Physical - Ensuring the physical protection of information systemsincluding the protection of related buildings and equipment fromnatural and environmental hazards and unauthorized intrusion. Technical - Identifying technology to be utilized and ensuringprocedures are in place to protect ePHI and to control access to it.

Computer Sign-on Access PC users at work are not to: Disclose, share or post sign-on codes Use sign-on codes to obtain access tounauthorized information Use someone else’s sign-on code

Information Management PC users at work are not to: Use, acquire, transmit, or duplicateunauthorized software. Alter or copy for non-business purposesany Health System information.

Prevent Access toUnauthorized Information Do not: Leave a computer unlocked with logon Leave data unattended or unlocked Email confidential information unless encrypted &decrypted using a TUHS approved method Remove information from the worksite via laptops,diskettes or printouts without prior approval fromthe owner of the information

Important PoliciesInformation Management DO NOT Access or communicate any patient informationelectronically, physically, verbally or in writingwithout prior written approval by management. Disclose any Health System businessinformation or personnel information withoutprior official approval.

IMPORTANT!! TUHS has the right to review all work activityto ensure that it is appropriate and beingconducted in the interests of the Health System. TUHS will operate in full compliance withHIPAA.

Corporate Compliance Program . STANDARDS OF CONDUCT . 5. Accurate Records:All billing and patient records will be accurate, complete and as detailed as required by government and professional standards. Each step in the treatment process, from admission through discharge, shall be documented appropriately in the patient’s medical records.

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