Breaking Compliance News Blog

Enter MPA’s 25th Birthday Compliance Giveaway!

Posted by Margaret Scavotto, JD, CHC on 6/2/20 10:00 AM


MPA turns 25 in June 2020!

That’s right, we are as old as eBay, and Kendall Jenner. In 1995, the first Honda CR-V was made, and so was MPA. Braveheart began its legacy in 1995 and so did we.  

We are proud that we have been helping healthcare providers for a quarter century, and we appreciate that we have earned your trust. We wish we could invite each and every one of you to a party to celebrate, but the pandemic has other ideas. Instead, we are saying thank you for 25 years of business with a giveaway.

This June, we are giving away a 12-month license to a Compliance Toolkit, ($1,750). We are also giving away our HIPAA Tools ($995).

Click here to enter. We’ll announce the winner by email at the end of June.

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Topics: Compliance Basics, HIPAA

HIPAA reminder: Is your workforce changing?

Posted by Margaret Scavotto, JD, CHC on 5/19/20 10:44 AM

Many providers are seeing changes to their workforce during the pandemic. Hospitals are recruiting additional healthcare professionals; nursing homes are relying more heavily on agency staff as employees become ill or do not show up for work. CMS has changed rules, allowing expanded types of providers to order tests and perform other tasks. An increased number of students or volunteers are also being used.

With these workforce changes, HIPAA training must continue. The HIPAA privacy and security rule remain in place during the pandemic. OCR enforcement remains active. HIPAA requires providers to train their workforce on HIPAA requirements. Workforce means “employees, volunteers, trainees, and other persons whose conduct, in the performance of work for a covered entity or business associate, is under the direct control of such covered entity or business associate, whether or not they are paid by the covered entity or business associate.”  45 CFR 160.103

HIPAA training reminders:

  • Covered entities should routinely evaluate who is working on their behalf and determine who is included in their workforce (and needs training).
  • The Privacy Rule requires covered entities to train all workforce members on policies and procedures related to PHI, as necessary and appropriate for the workforce members to carry out their functions. 45 CFR 164.530(b)
  • The Security Rule requires covered entities to: “implement a security awareness and training program for all members of its workforce (including management)” 45 CFR 164.308(a)(5)
  • Workforce members should also be trained to recognize breaches, how to report them internally, and who to report them to.
  • All workforce member should be trained on appropriate social media use (this is especially important during a national emergency).

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Topics: HIPAA, Social Media, security, breach notification, COVID-19, privacy

Using Social Media Safely During a Pandemic

Posted by Margaret Scavotto, JD, CHC on 5/14/20 9:20 AM

During a national public health emergency, healthcare providers will have many reasons to use social media. The community will likely turn to social media to learn what your organization is doing in response to COVID-19. Social media can be used to keep the public informed, ward off panic, advise patients and loved ones of new procedures or protocols, and show the public a strong response during the disaster. Social media is also being used to recruit staff, volunteers, and supplies.

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Topics: Social Media, security, business associates, compliance, COVID-19, privacy

Stay informed with MPA's Monthly Compliance Newsletter

Posted by Margaret Scavotto, JD, CHC on 5/12/20 10:45 AM

MPA scours OIG, DOJ, FBI, and OCR enforcement updates and news headlines so you don't have to.

Every month, we summarize enforcement trends and deliver the latest compliance and HIPAA developments to your inbox with our Monthly Compliance News Report.

Coming to this month's issue:

  • DOJ stops phony COVID-19 "ozone therapy"
  • Rehab company pressured SNF therapists to provide Ultra High Therapy
  • Executives pay up for unnecessary tests
  • DOJ wants mandatory breach reporting
  • Some enforcers offer discretion during the pandemic

  • FBI warns of PPE scams

  • Nursing home sued for response to COVID-19
  • Hackers targeting small healthcare providers, executives

  • HIPAA reminder: Is your workforce changing during the pandemic?

Not yet a subscriber? click here to sign up.  

You can read a sample report here

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Topics: Compliance Basics

OCR issues guidance on media access to patients

Posted by Margaret Scavotto, JD, CHC on 5/6/20 2:35 PM

On May 5, the OCR issued guidance addressing media access to PHI during the pandemic: OCR Issues Guidance on Covered Health Care Providers and Restrictions on Media Access to Protected Health Information about Individuals in Their Facilities. The OCR’s purpose in issuing this guidance is: “reminding covered health care providers that the HIPAA Privacy Rule does not permit them to give media and film crews access to facilities where patients’ protected health information (PHI) will be accessible without the patients’ prior authorization.” 

During COVID-19, providers are still required to obtain HIPAA authorizations from patients BEFORE the media is given access to patient PHI. This includes film crew access, and access to parts of the facility where patient PHI is accessible to the media in written, electronic, oral, or other visual/audio form. The OCR makes clear that every patient who will be in an area accessed by the media must sign a HIPAA authorization BEFORE the media has access.

Providers CANNOT require a patient to sign a HIPAA authorization as a condition of receiving treatment.

Masking or blurring patient faces or voices (which occurs AFTER the media has access to patients) is NOT enough to comply with HIPAA, unless a HIPAA authorization is obtained BEFORE the media has patient access.

If HIPAA authorizations are obtained in advance, and the media is given access to your facility, the OCR recommends safeguards to protect PHI:

  • Use computer monitor privacy screens
  • Install opaque barriers to block film crew access to PHI of patients who did not sign an authorization

This new guidance elaborates on prior OCR guidance about communicating with the media, including film crews.

Prior to the pandemic, the OCR entered two settlements with providers who allowed film crews access to patients without a proper HIPAA authorization:

  • In 2016, New York Presbyterian Hospital entered a $2.2 million settlement for what the OCR called an “egregious disclosure.” The hospital allowed the ABC TV show NY Med to film two of its patients in the emergency room, without obtaining their authorization. One of the filmed patients was dying; the other was in distress. Filming continued after a medical professional objected. One of the patients filmed was Mark Chanko, a gentleman who was taken to the hospital after he was hit by a garbage truck. When NY Med aired, Mr. Chanko’s voice was muffled and his face was blurred – but he was still recognized by his widow
  • In 2018, the OCR entered a $999,000 settlement with three Boston hospitals who allowed film crews from ABC to film on the premises without obtaining HIPAA authorizations. 

HIPAA media breaches are not limited to film crews:

  • In 2017, a Texas health system entered a $2.4 million settlement with the OCR. A patient presented a fake ID at the system’s OB/GYN clinic. The clinic called the police, which complied with the Privacy Rule’s provisions for reporting a crime on the premises. But, then the health system issued a press release about the arrest – and the press release title included the patient’s name. 
  • In 2013, a medical center entered a $275,000 with the OCR after senior leaders of the medical center “met with media to discuss medical services provided to a patient” and “impermissibly shared details about the patient’s medical condition, diagnosis and treatment in an email to the entire workforce.” 

MPA’s HIPAA & COVID-19 Tool Kit has been updated to include a HIPAA & the Media Policy in response to this guidance.

Read more HIPAA & COVID-19 updates on the blog.


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Topics: HIPAA, compliance, COVID-19, privacy

Sign up for MPA's May Compliance & COVID-19 Webinars

Posted by Margaret Scavotto, JD, CHC on 5/4/20 10:12 AM

I hope you can join me for MPA's upcoming complimentary webinars:

For all providers:

Keeping Compliant During COVID-19

May 19, 2020, 12 CST



For nursing homes:

Phase 3 Compliance Webinar: Social Media Compliance During a Pandemic

May 27, 2020, 12 CST

Register now


Zoom will email you a link to access the webinar - and I will also send this link around the day before the webinar.

Have a great day!

COVID-19 Discounts:

  • All digital download HIPAA Tool Kits are 50% off until June.
  • Compliance program annual reviews are 25% off until June (call or email me for info)
  • Our HIPAA & COVID-19 Toolkit is available at the discounted price of $95.
  • MPA will continue putting out HIPAA announcements, news, and tips on the blog
  • MPA has free compliance and HIPAA resources on its Free Resources page.  

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Topics: compliance, Phase 3, COVID-19

Protect your organization from skyrocketing COVID cyber scams

Posted by Scott Gima on 4/30/20 11:00 AM

Google’s Threat Analysis Group (TAG) is responsible for identifying online vulnerabilities and threats. The Group released a report on April 22, 2020 that describes their latest information on COVID-19 related threats. This report provides a timely reminder that cybersecurity concerns continue and everyone must remain cautious and vigilant with their email accounts.

COVID-19 Themed Attacks

In April, Google has detected 18 million COVID-19 related malware and phishing Gmail messages per day and more than 240 million COVID-related daily spam messages. If you use Gmail, 99.9% of these messages never reach your inbox. The TAG has found that these attacks are government sponsored. They have identified over a dozen government-backed attacker groups using COVID-19 related topics.

Type of Attacks

The attack tools are no different from what has been used in the past; phishing emails that lure you to click malicious links or download files that contain malware. Google provided the following examples:

Free meals and coupons in response to COVID-19.

Links to malicious websites disguised as online ordering and delivery options, where the recipient is asked to provide their Google account credentials.

Emails that impersonate the World Health Organization:

Emails luring users who may be working from home:

Stimulus package theme:

Best Practices Reminder

These types of attacks are not limited to Gmail and everyone must be vigilant with all email accounts, work and personal. For all your accounts, users should:

  • Never download file attachments - or, verify an email attachment with the recipient by voice or text before downloading – this is an old-fashioned version of two-factor authentication.
  • Don’t click on an email link. An alternative safe option is to go directly to the web-page or google the target described in the link. For example, if it is an email from your bank that could be legitimate, open a new browser page and type in the website or search for the website.
  • If possible, use or activate two-factor authentication.

MPA can help with your HIPAA Security Risk Analysis - contact me today to learn more.

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Topics: HIPAA, security, COVID-19

What do we do about compliance now?

Posted by Margaret Scavotto, JD, CHC on 4/28/20 10:00 AM

How should COVID-19 affect your compliance program progress? Do we keep going? Halt? Or is the answer somewhere in between?

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Topics: COVID-19

HIPAA & COVID-19 Toolkit UPDATED for new OCR Business Associate Guidance

Posted by Margaret Scavotto, JD, CHC on 4/2/20 3:08 PM

***To help providers with HIPAA compliance during the COVID-19 pandemic, all MPA HIPAA Tool Kits are now marked down to 50% off. 

Business Associate Disclosures during COVID-19

On April 2, 2020, the OCR issued a Notification of Enforcement Discretion under HIPAA to Allow Uses and Disclosures of Protected Health Information by Business Associates for Public Health and Health Oversight Activities in Response to COVID-19

This Notification, effective immediately, announces that the OCR will NOT impose HIPAA penalties against a business associate or covered entity under the following Privacy Rule provisions, in some circumstances. Enforcement is waived for the following Privacy Rule sections:

  • 45 CFR 164.502(a)(3): Business Associates: Permitted Uses and Disclosures
  • 45 CFR 164.502(e)(2): Disclosures to Business Associations: Documentation
  • 45 CFR 164.504(e)(1): Business Associate Contracts
  • 45 CFR 164.504(e)(5): Business Associate Contracts with Subcontractors

Enforcement of these sections will not occur in the following circumstances:

  • A business associate makes a good faith use or disclosure of the covered entity’s PHI for public health activities consistent with 45 CFR 164.512(b) or health oversight activities consistent with 45 CFR 164.512(d); AND
  • The business associate informs the covered entity within 10 calendar days after the use or disclosure occurs (or commences, with respect to uses or disclosures that will repeat over time).

If a business associate makes one of these disclosures, and the covered entity and business associate have not had time to update their business associate agreement to allow for such disclosures, OCR will not impose penalties.

An example of how this waiver might apply to you might be:

  • If a business associate is contacted by the local public health department and asked questions during a health investigation related to a COVID-19 patient. The business associate will be permitted to disclose information to the public health department. This type of disclosure is not typically permitted, if it is not specifically outlined in the BAA. However, under this waiver, the business associate may disclose the requested information to the public health department. Within 10 days of the disclosure to the public health department, the business associate must inform the covered entity that the disclosure was made. 

Business associates are STILL expected to comply with the Security Rule. For example, ePHI must be securely transmitted to the public health authority or health oversight agency.

MPA's HIPAA & COVID-19 Toolkit was updated April 2 for the new OCR guidance on business associates.

HIPAAtrek and MPA are here to help navigate and guide HIPAA compliance. Our priority is you – our clients, our healthcare providers, and healthcare administrators. We understand that this is a confusing and scary time. Now more than ever, please reach out with your compliance questions. We are here to help alleviate your compliance burden both now and in the future. Stay healthy.


Margaret and Sarah

Check out our other HIPAA & COVID-19 blogs:

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Topics: HIPAA, data breach, security, COVID-19, privacy

HIPAA & COVID-19: telehealth

Posted by Margaret Scavotto, JD, CHC on 3/27/20 12:00 AM

Blog Series: Staying HIPAA Compliant During COVID-19

Sarah Badahman, CHPSE, Founder/CEO, HIPAAtrek, St. Louis 

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Topics: HIPAA, data breach, security, COVID-19, privacy

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