Privacy and Confidentiality Report
Name
Institution
Author’s Note
Compliance Violations
In the first violation, a USB was left unattended and readily accessible even to strangers. This is a grave violation of the law governing the security of health records. The Centre for Medicare and Medicaid Services (CMMS) set up requirements that need to be met by healthcare providers in securing the privacy of patients in health records (CMS Minimum Security Requirements (CMSR)). The Code of Federal Regulations also provide for security standards that are meant to protect the privacy of health records (Health Insurance Portability and Accountability Act of 1996 (HIPAA)). Accordingly, health institutions are required to make guidelines that limit access to electronically stored information.
The institution violated the HIPPA security assessment rule by taking too long to do to assessment. Interestingly, the staff could not remember the last time the assessment was done. Besides, an office laptop was missing. The laptop contained sensitive patient information. The Code of Federal Regulations provides that it is the obligation of healthcare facilities to conduct risk assessment (HIPAA 1996, 308).
Ben also noticed a whiteboard that contained all patients’ sensitive data. This also violated the provision of the guidelines on privacy. Notably, the Code of Federal Regulations provides that health institutions must ensure technical safeguards to protect patients’ data from being accessed (HIPAA 1996, 312). Such safeguards involve using technological means, like computers, to store patients’ data.
Regulatory Stakeholders
First, the Joint Commission on Accreditation of Healthcare Organizations (“JCAHO”) is a commission formed to accredit healthcare institutions (The Joint Commission, 2021 National Patient Safety Goals (NPSG)). Accordingly, JCAHO ensures healthcare institutions meet the standards set in the HIPAA and other regulatory bodies.
The National Committee for Quality Assurance (NCQA) set standards that measure performance of healthcare delivery (National Committee for Quality Assurance (NCQA), 2019).
As already mentioned above, the Centre for Medicare and Medicaid Services (CMMS) sets requirements that need to be met by healthcare providers in securing the privacy of patients in health records (CMS Minimum Security Requirements (CMSR)).
Patient and Provider Rights
Patients have several rights. First, they have the right to receive appropriate health care. Next, they have the right to informed consent where their consent is required for them to receive healthcare services. They also have the right to privacy. Accordingly, their medical records should not be disclosed. Patients have the right to be informed of any concern they have during healthcare. Lastly, they have a right to access medical records. On obligations, patients have an obligation to pay for healthcare services. They should also be honest and respectful to the providers. Finally, patients have a duty to avoid predisposing other people to risk.
Providers, on the other hand, also have rights. First, they have the right to set a limit to healthcare services they offer, or procedures that they do Giallanza v. Sands (1975). Accordingly, healthcare providers have the latitude to define their operations. Next, they have a right to receive payment for their services. Lastly, they should have in place an effective dispute resolution mechanism. On duties and responsibilities, providers have a duty to communicate with the patients. They should also avoid discriminating on the clients. Healthcare providers have a duty of care. Under this duty, they are required to take every reasonable step to take care of the health of the patients. Healthcare providers also have a duty to ensure they protect the records of the patients according to the applicable laws and regulations (HIPAA 1996, 308).
The regulations put in place by the mentioned bodies have gone a long way in shaping the quality of healthcare. For instance, healthcare providers have to adopt the requirements of the regulatory bodies. And as a result, the quality of healthcare is improved. On the other hand, providers have been found liable for privacy infringement when they maintain poor record keeping.
Compliance and Risk Management Factors of the Medical Records
The first risk management issue in the first scenario is that non-authorized personnel can get access to the USB drive and look at Patients’ sensitive medical data. Accordingly, the institution had a duty to store such devices in a proper manner (HIPAA 1996, 308).
The second risk management issue is that the institution had taken too long to conduct a security assessment, the institution should ensure that a frequent security check is done to protect the records (HIPAA 1996, 308).
Lastly, Ben noticed patients’ data written on a public place. The hospital has an obligation to adopt record keeping services that are updated (HIPAA 1996, 312).
REFERENCE
Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 CF § 164.
CMS Minimum Security Requirements (CMSR) Version 1.5, July 31, 2012.
Giallanza v. Sands, 316 So. 77, 83 (Fla. App. 4th Dist. 1975).
National Committee for Quality Assurance (NCQA), 2019 Standards and Guidelines for the Accreditation of Health Plans.
The Joint Commission, 2021 National Patient Safety Goals (NPSG).
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