Breaking Compliance News Blog

*Free Issue* MPA’s Compliance and HIPAA News Reports

Posted by Margaret Scavotto, JD, CHC on 1/26/23 12:03 PM

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Topics: Training and Education, compliance

Earn CEUs with MPA's FREE Compliance & HIPAA Webinars!

Posted by Margaret Scavotto, JD, CHC on 1/18/23 8:15 AM

 

 

Sign up for MPA's FREE Compliance & HIPAA webinars:

All webinars start at 11:00 a.m. CST and are presented by Margaret Scavotto and Scott Gima

HIPAA Security Update

January 25, 2023

90 minutes

1.8 CCB CEUs

Healthcare is the #1 target of cyber-attacks, and the threat continually increases. Your HIPAA security program is your defense, and the key to maintaining continuity of care. In this webinar, we will illustrate why the HIPAA Security Risk Analysis is the best way to identify and reduce security risks and prevent cyber-attacks. We will also address the 2021 HITECH amendment’s Recognized Security Practices for covered entities and business associates: what providers can and should implement, and how doing so can yield favorable results after a breach. This webinar will also cover new and emerging risks from the Office for Civil rights, news coverage, and best practices.

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Plan a Successful Compliance Week in 2023

February 22, 2023

90 minutes

1.8 CCB CEUs
1.5 NAB CEUs

Your compliance program is only as strong as the culture behind it - and the knowledge and buy-in of your team. It takes year-round activities and awareness to support that culture. In this webinar, we will discuss approaches to plan a fun and engaging Compliance Week for your staff. Whether it's been a year since you held Compliance Week - or whether compliance has been back-burnered during the pandemic and your culture needs a boost - it's time to schedule a Compliance Week!
 
Learn how to plan a Compliance Week that includes employee feedback, and reinforces compliance as a positive force in your organization.

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This program has been approved for Continuing Education for 1.5 total participant hours by AB/NCERS—Approval #20240221-1.50-A90033-DL.

 

SNF Compliance Update

April 19, 2023

90 minutes

1.8 CCB CEUs

1.5 NAB CEUs

It’s been a long road since the Affordable Care Act mandated compliance and ethics programs for nursing homes in 2010. Since then, we have had rules issued; enforcement delayed; a pandemic; and, as of October 24, 2022, enforcement via CMS survey. Compliance is never easy in the highly regulated world of long-term care – but it has only gotten harder since this mandate was announced.
 
In this webinar, we will discuss the status of compliance and ethics programs for nursing homes; review other reasons to comply (DOJ, OIG, OCR, etc.); walk through a step-by-step process to implement or review your program; and identify best practices for a compliance program that lasts.
 

This program has been approved for Continuing Education for 1.5 total participant hours by NAB/NCERS—Approval #20240418-1.50-A90034-DL

The Compliance Certification Board (CCB)® has approved these events for up to 1.8 ive CCB CEUs based on a 50-minute hour, each. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.

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Topics: Training and Education, HIPAA, compliance

Earn CEUs with MPA's FREE Compliance & HIPAA Webinars!

Posted by Margaret Scavotto, JD, CHC on 1/11/23 10:40 AM

 

 

Sign up for MPA's FREE Compliance & HIPAA webinars:

All webinars start at 11:00 a.m. CST and are presented by Margaret Scavotto and Scott Gima

HIPAA Security Update

January 25, 2023

90 minutes

1.8 CCB CEUs

Healthcare is the #1 target of cyber-attacks, and the threat continually increases. Your HIPAA security program is your defense, and the key to maintaining continuity of care. In this webinar, we will illustrate why the HIPAA Security Risk Analysis is the best way to identify and reduce security risks and prevent cyber-attacks. We will also address the 2021 HITECH amendment’s Recognized Security Practices for covered entities and business associates: what providers can and should implement, and how doing so can yield favorable results after a breach. This webinar will also cover new and emerging risks from the Office for Civil rights, news coverage, and best practices.

SIGN UP

 

Plan a Successful Compliance Week in 2023

February 22, 2023

90 minutes

1.8 CCB CEUs
1.5 NAB CEUs

Your compliance program is only as strong as the culture behind it - and the knowledge and buy-in of your team. It takes year-round activities and awareness to support that culture. In this webinar, we will discuss approaches to plan a fun and engaging Compliance Week for your staff. Whether it's been a year since you held Compliance Week - or whether compliance has been back-burnered during the pandemic and your culture needs a boost - it's time to schedule a Compliance Week!
 
Learn how to plan a Compliance Week that includes employee feedback, and reinforces compliance as a positive force in your organization.

SIGN UP

This program has been approved for Continuing Education for 1.5 total participant hours by AB/NCERS—Approval #20240221-1.50-A90033-DL.

 

SNF Compliance Update

April 19, 2023

90 minutes

1.8 CCB CEUs

1.5 NAB CEUs

It’s been a long road since the Affordable Care Act mandated compliance and ethics programs for nursing homes in 2010. Since then, we have had rules issued; enforcement delayed; a pandemic; and, as of October 24, 2022, enforcement via CMS survey. Compliance is never easy in the highly regulated world of long-term care – but it has only gotten harder since this mandate was announced.
 
In this webinar, we will discuss the status of compliance and ethics programs for nursing homes; review other reasons to comply (DOJ, OIG, OCR, etc.); walk through a step-by-step process to implement or review your program; and identify best practices for a compliance program that lasts.
 

This program has been approved for Continuing Education for 1.5 total participant hours by NAB/NCERS—Approval #20240418-1.50-A90034-DL

The Compliance Certification Board (CCB)® has approved these events for up to 1.8 ive CCB CEUs based on a 50-minute hour, each. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.

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Topics: Training and Education, HIPAA, compliance

Did you brush your teeth?

Posted by Margaret Scavotto, JD, CHC on 1/10/23 8:30 AM

My kids sometimes ask me why they have to brush their teeth every day. Or put away their dirty laundry EVERY DAY. We did that yesterday, Mom. Isn’t that enough? Come on.

This always prompts a conversation about habits, and what happens when we skip them.

If we skip brushing our teeth once, we are likely to skip brushing our teeth again. And again. And again. Until not brushing our teeth becomes the habit.

Until…. It’s time to go to the dentist. If we’ve skimped on brushing, we might not get that sticker. No Dora the Explorer toothbrush. Nope, you’ve got cavities. That means TWO trips to the dentist. For grown-ups, who always have the most fun, it could mean a root canal or an impacted tooth – maybe even THREE trips to the dentist.

You know where I’m going with these oral hygiene horror stories.

How are your compliance habits?

Compliance is a routine. It’s not a one-and-done job. There are annual, quarterly, monthly, weekly, and daily tasks.

What happens if we forget to log a compliance complaint? Just one. Or two? What does that do the integrity of our documentation? How will we defend questions or concerns about this complaint at a later date? How will it impact the data we have available to identify complaint trends? How can we prove we handled this complaint?

What happens if we forget to do our HIPAA walk-through audit this quarter? And maybe next quarter, because things are still really busy? How long have employee passwords been left up on post-it notes for visitors to see? How long have the water cooler patient conversations gone unchecked? What are we missing that we haven’t even thought about?

What happens if we skip our weekly compliance rounding, when we walk the halls and interact with employees? How many interactions do we miss? How many employees stop recognizing us – and think a little less about compliance?

The biggest habit of all is, of course, a semi-annual visit to the dentist. In the compliance world, this is your annual compliance program review. If we have been keeping up compliance habits, that annual review will find more successes to celebrate (Dora the Explorer toothbrushes for everyone!) If, however, we have let those habits fall by the wayside, we might need to fill some cavities in the next year. Or worse – conduct a root canal.

At the dentist’s office and in the compliance department, habits matter. Skipping them can have a big impact. Focus on the habits that keep your compliance program effective and commit to them. And do not, under any circumstances, make a habit of skipping the annual compliance program review.

So I ask you: Are you regularly brushing your teeth?

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Topics: compliance

The Rackspace ransomware attack – How safe is your cloud?

Posted by Scott Gima on 12/20/22 10:40 AM

What is Rackspace?

Rackspace Technologies is a tech company that provides cloud-based servers, data storage and data backup services.

What Happened?

On December 2, 2022, at 2:49 a.m. EST, Rackspace posted a message stating that customers that used their hosted exchange email servers did not have email access. The Hosted Exchange services include mailboxes (up to 100GB), Microsoft Outlook, Outlook Web Access, mobile device synchronization, anti-spam and anti-virus protection.

On 12/6, Rackspace indicated that they suffered a ransomware attack.

Rackspace has not yet indicated when email service will be restored to their clients. In the meantime, email accounts and domains are being migrated to Microsoft 365. This temporary solution only provides access to new emails. Clients currently have no access to existing emails.

Rackspace has not reported the number of impacted customers. It has been speculated that the number of small and medium sized customers may be in the thousands.

Why is this Important?

In the old days, Microsoft Outlook and Office programs were installed on your company’s server. Email Exchange Servers were also physically located within your company. All emails, email attachments, documents, and spreadsheets were also stored on the server or on your desktop. Today, companies like Rackspace and Microsoft provide these applications with data storage in the cloud.

The Rackspace incident provides a sobering example that cloud applications and cloud stored data are not as safe as you think. Rackspace customers lost the ability to receive and send emails. According to news reports, many customers have email after Rackspace moved them over to Microsoft 365. But there is an ongoing concern of archived email data loss once email service is restored. Think about the impact to your organization and your job tasks if you lost the ability to send and receive emails, plus access to all of your old emails, both sent and received. My guess is that you will come to the same conclusion as me – the impact would be significant if not catastrophic.

Impact?

Loss of email typically means lost revenue. What is your organization’s tolerance to downtime? In other words, how long can you go without email? These are questions that need to be posed to each department. The loss of access to the EHR is the #1 issue, but that can be handled by going old school with paper documentation. The impact on other departments must be reviewed in detail.

Let’s start with the business office. Is there enough cash if billing Medicare, Medicare Advantage, Medicaid and private pay stops or takes longer than normal? What about follow-up of unpaid claims? Referrals? Communication with referring hospitals is typically handled by email. How do you review payor eligibility? How will you recruit staff for open positions without receiving email notifications from recruiting websites? Background checks and review of exclusion lists? The list goes on and on.

All of us are heavily dependent on emails to do our daily tasks. The temporary loss of being able to send or receive emails for a week or two is tolerable, but the tipping point may well be the possible loss of old emails and attachments.

What to do?

I reached out to Scott Wolff, President and Director of IT Operations at LanServ, Inc., a managed service provider (MSP) in St. Louis, and asked him: What do companies need to do to limit their email downtime and prevent the loss of archived (old) emails and attachments? Here is a list of recommendations from Scott W:

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Topics: HIPAA, security, compliance

Compliance Lessons from Mistletoe, the Elf on our shelf

Posted by Margaret Scavotto, JD, CHC on 12/19/22 10:40 AM

 
A few years ago, we begrudgingly began participating in the Elf on the Shelf tradition.
 
I say begrudgingly because, while the Elf brings a lot of merriment, it’s also a lot of work for parents. And, something about the tradition feels a little too much like playing a trick on the kids.
 
Nevertheless, the Elf joined our household in 2020. The pandemic and virtual school were upon us, and we needed some joy, ASAP. We also got a puppy during this time (if you are wondering how things were really going). The kids named the Elf Mistletoe. But the story we told our kids about Mistletoe strays from tradition.
 
The original Elf on the Shelf story tells children that Santa sent the Elf to sit on their shelf and keep an eye on the kids. If the kids are good – or bad – the Elf will report this news back to Santa at the North Pole, and that will, understandably, impact the children’s gifts under the tree. The original Elf tale also warns kids to never, ever touch the Elf – or the Elf will lose its magic.
 
Yikes! That’s a lot to worry about. Aren’t the holidays supposed to be fun? Especially for kids?
 
So we changed the story. In our house, Mistletoe comes to spread holiday cheer. She comes to celebrate that the kids were good this year, and to bring a little magic into the season. We also told the kids that the Elf does not lose her magic if they touch her. We compared that legend to “step on a crack and you’ll break your mother’s back.” It’s not going to happen. Because inevitably, a kid will touch the Elf out of burning curiosity and then spend the night in tears (rather than sleeping).
 
Is your Elf celebrating or scaring?
 
Much like my family decided to take control over the narrative surrounding Mistletoe the Elf, the compliance department has choices when it comes to its compliance messaging.
What kind of message does your compliance program convey?
 
Does your compliance department focus on the penalties and punishments looming if people slip up? Do you send a lot of emails or post a lot of reminders featuring the words “Don’t” and “No”?
 
Or does your compliance department focus on helping your team do their jobs in a way that honors the compliance program – and celebrating the successes along the way? Maybe you use more words like “Remember” and “Here’s a tip!”
 
I want my kids to smile when they see the Elf every year, rather than feel a sense of impending doom. Compliance officers also want to be well received. Is your compliance message as inviting as you’d like your compliance culture to be?
 
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Topics: compliance

Compliance Lessons from the #BettyWhiteChallenge

Posted by Margaret Scavotto, JD, CHC on 12/14/22 8:45 AM

 

As 2022 comes to a close, I have been revisiting the year’s formative events, and trying to focus on the positive ones. Betty White made the list.

Betty White died on December 31, 2021. She was 99.



To honor her 100th birthday – January 17, 2022 – the internet buzzed with the #BettyWhiteChallenge.

Because Betty was a life-long animal lover and advocate, Betty White fans across the country rallied together to raise money for animal shelters in her name. The call? Donate $5 to a local animal shelter in Betty White’s name. My favorite animal shelter, Stray Rescue of St. Louis, gave a “Thank you for being a friend” shirt to everyone who donated $100 or more.

The response exceeded the call: Almost 400,000 people contributed a total of $12.7 million for the cause, in a single day. That’s about $30 per person – not a huge amount. But collectively, fans of Golden Girl Rose raised more than twelve million dollars. That’s a lot of money gathered with an initial request of $5.

Small contributions matter.

Compliance can feel like a mountain to climb. A never-ending to-do list that lengthens, rather than shortens, each day. A Herculean task.

If that’s how compliance feels to you, or to your organization, think small. Think five minutes instead of five dollars. What can you do in five minutes a day? Could you check in with one department head to see where they need compliance help, or how an auditing initiative is going? That would add up to a lot of conversations in a short amount of time.

What could you do in thirty minutes per week? Could you schedule a routine walk around the halls, meeting employees individually with a quick compliance trivia question? If you spent 30 minutes doing this every week, how many people would you talk with in six months?

This is of course an oversimplification of the hefty work behind compliance. A lot of what we do can’t be done in five minutes, or an hour. Larger time commitments will always be needed. But don’t overlook the positive impact of little efforts. When you commit to those daily, weekly, and monthly tasks, they will grow into meaningful results. And meaningful results provide great motivation – and momentum – for those bigger, mountainous tasks.

Just think of what things will look like a year from now if you commit 10 minutes a day, or a week, to a task. As Betty White (as Rose) would say, I’ll get the cheesecake while we wait.

 

 
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Topics: compliance

No copycats: Finding your compliance voice

Posted by Margaret Scavotto, JD, CHC on 12/13/22 8:15 AM

Ask a kid what they want to be when they grow up, and you’ll hear a lot of “I want to sing like Taylor Swift!” and “I want to play football like Tom Brady!” or “I want to go to outer space like Elon Musk!”

It’s good to have a goal, and I want these kids to reach for the stars – as long as they remember what they bring to the table.

Taylor Swift, for example, is an alto. Tom Brady is a quarterback. And Elon Musk has lots of billions of dollars.

If the child is a soprano, she will never sing like Taylor Swift. Only one human in the world can be Taylor Swift. Anyone who tries to sing like Taylor Swift will inevitably fail.

The same is true for the aspiring quarterback who is also an excellent sprinter and would, in fact, make a great running back. And while you don't need billions of dollars to succeed as an entrepreneur and travel to outer space just for fun, the path might look different.

Lest you think I’m the anti-hero, keep this in mind: A child who wants to be a famous singer should use their own unique, beautiful voice. A child who wants to be a professional football player should play lots of football and figure out which position suits their natural talents. And an aspiring entrepreneur should spend their formative years learning which of their unique talents are most likely to translate into a successful business venture.

Cover bands don’t get record deals.

It’s good to have role models and to look elsewhere for inspiration. But what we bring to the table comes from within, that uniqueness, should not be underestimated.

A new Compliance Officer inheriting a decades-old compliance program from an experienced predecessor should soak up the lessons that are handed down. But the new professional should not stop there. He or she should also look inward and ask: What do I bring to this job? What ideas and strengths do I have that will make this program into something new?

New eyes often provide a fresh perspective. What can you change for the better?

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Topics: Compliance Officer & Committee, compliance

Understaffing increases cybersecurity risk

Posted by Scott Gima on 12/6/22 10:21 AM

Workforce statistics: An (ISC)2 workforce survey of 11,779 cybersecurity practitioners and decision makers reported strong increases in cybersecurity workers:

  • The US cybersecurity workforce increased by 5.5% between 2021 and 2022.
  • Globally, the increase was 11.1%, or 464,000 new workers.

But demand for cybersecurity workers increased almost twice as fast resulting in an increase in need. In the US, the workforce gap increased by 9.0%. The global gap has climbed by 26.2% since 2021.

Why it matters: For organizations, unfilled cybersecurity jobs increase the risk of a successful cyber event. The (ISC)2 survey identified multiple staffing related problems:

  • 70% of organizations don’t have enough cybersecurity staff to be effective.
  • More than half believe their organization is at a “moderate” or “extreme” risk of cyberattack.
  • Oversights in certain procedures have been made.

These vulnerabilities worsened in 2022:

  • Not enough time for proper risk assessment and management
  • Oversights in process and procedure
  • Slow to patch critical systems
  • Not enough time to adequately train each cybersecurity team member and not enough training resources
  • Misconfigure systems

The top four reported reasons for the shortage:

  • 43% - my organization can’t find enough qualified talent.
  • 33% - My organization is struggling to keep up with turnover and attrition.
  • 31% - My organization doesn’t pay a competitive wage.
  • 28% - My organization doesn’t have the budget.

Tackling the problem: Multiple strategies were identified by the (ISC)2 survey. While all had a positive impact, some were more effective. Organizations that focused on training were least likely to have staffing shortages. These organizations focus on rotating job assignments, mentorship programs and encouraging employees outside of cybersecurity to join the field. Organizations that outsourced cybersecurity showed a higher percentage of staffing shortages. Effective strategies include the following:

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Topics: HIPAA, security, compliance

Making Recognized Security Practices work for you

Posted by Scott Gima on 11/30/22 10:15 AM

One Big Thing

IImplementation of Recognized Security Practices (RSPs) for at least 12 months provide covered entities and business associates with the opportunity to reduce fines and penalties for violations of the HIPAA security rule.

Background

On January 5, 2021, Congress passed an amendment to the HITECH Act that requires the OCR to take into account the Recognized Security Practices of covered entities and business associates when they are able to show that RSPs have been in use for the 12 months prior to a HIPAA breach incident.

If RSPs are in place, the OCR may mitigate fines and remedies and allow an early and favorable termination of an audit..

Over the past months, the amendment has generated questions related to the uncertainty about what constitutes RSPs, and how to demonstrate their implementation. In response, on October 31, 2022, HHS-OCR released a video that addresses some of these concerns about RSPs.

What Are Recognized Security Practices?

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Topics: HIPAA, security, compliance

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