Task 4 Sarah Phillips
Willow Bend Hospital’s compliance does indeed have multiple deficiencies and is in need of review as many were updated in 2009 and 2010. All information on deficiencies would be found on the latest updated version of the Joint Commission Information Standards. This should be located within the Corporate Compliance/Risk Manager’s office. As this information is not currently available to this writer without a subscription and fee, I must use the information available to me. So expansion and explanation of policy details are limited.
In 2010, the policy addressing terminology and abbreviations was integrated into the Information Management standards as elements of performance 2 and 3 under IM.02.02.0 by
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The Corporate Compliance/Risk Manager should also collaborate with department directors, Administration, and legal counsel to make sure appropriate actions for violations is upheld. Risk Management should also maintain HIPAA specific documentation a minimum of six years or as Joint Commission deems.
Department Directors should plan for employee education and training regarding privacy and confidentiality in cooperation with Staff Development. The directors should also monitor for compliance within their departments. The Staff Development department should be in charge of coordinating orientation, annual reviews, and periodic education and training. The Medical Records Director should develop an audit process to monitor compliance.
Knowledge-based information policy is found in Standard IM.03.01.01. Access of availability should be all the time, 24 hours a day, and 7 days a week. The HIM Manager should maintain information on knowledge-based information and the IT department should maintain electronic access.
An outside business can dispose of protected health information by purging or destroying electronic media. This is covered in 45 CFR 164.308(b), 164.314(a), 164.502(e), and 164.504(e). HHS HIPAA Security Series 3: Security Standards – Physical Safeguards is a good source for more information. The Medical Records Director should maintain documentation with all
6. Many drug safety research studies are sponsored by pharmaceutical companies that would financially benefit if the results of the study are favorable. Is this an example of a potential confounding factor?
In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.
The fifth member of the team is the medical records manager. She has a bachelors in healthcare management. Her expertise with HIPAA rules and regulations is crucial. It is her job to evaluate security of the new systems to ensure that patient confidentiality is not breached. She will have input form other healthcare managers as well as others in the medical records department.
But for another example a pizza shop in competition wit a fried chicken shop would be indirect because the products are not the same but they are still competing for sales.
Type of event, training, or exercise: (actual event, table top, functional or full-scale exercise, pre-identified planned event, training, seminar, workshop, drill, game, etc.)
mitigate these points assessments will be made in how to best mitigate the failure and what would need to be done to
I chose to study and analyze J.M.W. Turner’s Slave Ship for this project and found it to be very interesting. Immediately while looking at the piece you get a strong sense of emotion and drama that is being portrayed. There is a lot of depth and warmth in the colors that are used and wide swift brush strokes to create the images. The first image that caught my eye was of waves crashing on the left side of the painting. The white tips of the waves are very noticeable against the softer shades of the ocean. Behind the waves is a ship which is the next part of the painting that drew my attention. The ship seems to be caught in the rough waves of the sea and barely able to keep afloat. There is a glimmer of light from the sun peeking through
Presentation regarding the university’s Disaster Recovery Plan/Enterprise Continuity Plan including: basic structures; roles within the DRP/ECP plan; areas within a company if addressed improve resilience to catastrophic events, and an employee awareness campaign.
Develop a training plan for new HIM employees that will ensure that they understand the HIPAA regulations and what their role is in maintaining them.
What administrative safeguards are in place? (Administrative safeguards refer to the policies and procedures that exist in your practice to protect the security, privacy, and confidentiality of you patients’ PHI.) CLC converted into Electronic Health Record. The system they use is called Thereap. Therep allows staff to view individual’s medical records and make changes to their chart as need and keep track of their health records. Its secure and maintains a directory which contains identifiers required for Licensed Clinicians. All employees have to go through annual training on HIPPA Violations, Rights and Due Process, Corporate Compliance and Ethics, False Claims Recovery Act every year to stay in compliance. Each employee had to sign
recommendation for departmental compliance training or organization-wide compliance training. The departments leaders will be responsible for developing a compliance training plan, performing the designated training, then documenting who attended training as well as the training dates. Additional audits will be performed at three month intervals post-training to ensure Nightingale Community Hospital’s and The Joint Commission’s standards are met on a consistent basis.
Violations of regulatory compliance regulations often result in legal punishment, including federal fines. The OM must be informed and able to educate its staff/employees about the national patient safety goals, and take steps toward putting the right processes in place to achieve them. You may find that significant changes must be made, or it may be that a few simple modifications to your existing procedures can make a big difference. Either way is important to assess where your organization is achieving national patient safety goals, and where there are opportunities to improve, and then put a plan in place to implement change as
Everyone that has visited any medical office has heard the word HIPAA being used. HIPAA stands for the Health Insurance Portability and Accountability Act and was created to protect patient rights to obtain health insurance coverage when having a serious illness, injury, or pregnant and having a job loss. It limits exclusions for preexisting conditions. HIPPA also includes a patient privacy and security rule regarding the storage and communication of medical records. HR constantly deals with these records between health insurance plan information, medical leave of absences, and disability information. Supervisors and managers are often exposed to this information because employees want to be honest about reasons they do not show up for work. Thus, we must train supervisors and managers to keep employee medical information confidential. The HR department will do its due diligence to keep this information for employees in a separate place with restricted
The Compliance and Privacy Department answers request for assistance from every department, to include: ambulatory care, physician practice, hospital administration, allied health, nursing, transplant, imaging, health information management, pathology, transcription, coding, scheduling, finance, surgery, nurse triage, call management, revenue cycle, patient access, patient finance, pharmacy and information technology.
When organization exceeds standards expectation they decided to take it further to assure the company is implementing and improving quality care and safety. It express to the consumers that their human rights, treatments and infection control is their number one priority. This includes monitoring all licensed individuals credentials (to stay updated), accreditation (compliance), and functioning innovation (updated technology). The company will decide what regulatory body fit their company’s goals, mission and values. Organizations will have to abide by the CMS Condition for Participations (CoPs) and Condition for Coverage (DfCs). When a company decides exceeds those CMS’s standards they took steps to strengthen patient safety efforts, stay