HIPAA Breaches & Desk Audits

What is a breach?
In simple words, the loss of patient protected health information, either printed or electronic.

How common are breaches within pharmacies?
There are two types of pharmacies and pharmacy owners,
The first are the ones who know they have had a breach
The later are the ones who have had a breach and don’t know about it

How can I have a breach and not know about it?
Simple, has your pharmacy clerk ever given a patient another patient’s medication?

That is a breach

Can you give me examples of breaches?
Pharmacy is robbed and the will call bin is stolen
Pharmacy is robbed and the server is stolen
Staff pharmacist has a laptop stolen
Delivery driver has their vehicle stolen which is full of prescriptions to be delivered
Billing manager has a jump drive with patient files for billing to work at home and loses it on the bus

What do I do when a breach occurs?
First, don’t panic
Get the facts
Complete a Potential Breach Evaluation and a Risk Assessment
Determine whether the breach is reportable or non-reportable to HHS/OCR
Document everything 

What are OCR Desk Audits
Tested in 2016
Launched on January 1, 2017
Notification via U.S. Mail and Email
Also conducting no notice on-site inspections

What is the OCR asking for?
Notice of Privacy Practices (date must be after 07/01/2013)
Risk Analysis
Risk Management Plan
Disaster Recovery Plan/Contingency Plan
Annual Privacy and Security Assessments
Random Policies and Procedures

On-Site Inspections
Same as above, but in person
First question is to the person at your counter, normally your clerk
Can I have a copy of your Notice of Privacy Practice?
They have to know the answer and provide the NOPP

Penalties for Non-compliance
Fines up to 1.5 Million Dollars

 Is there help available to pharmacies?
Yes, but you get what you pay for
You can buy a set of policies and procedures, but if you have breach, especially a reportable breach:

Will the consultant stay with you when you need them the most?
Will they charge you extra?
Will they provide the correct advice?

How do you know how to pick a consultant?
Ask your peers
Ask hard questions about how they have handled client breaches and inspections
Do you get detailed answers from the consultant?
Do you referrals from multiple people?

CONTACT: Office:  724-357-8380 

Website:  www.rjhedges.com

HIPAA Breaches &amp; Desk Audits
What is a breach?
<ul>
<li>In simple words, the loss of patient protected health information, either printed or electronic.</li>
</ul>
How common are breaches within pharmacies?
<ul>
<li>There are two types of pharmacies and pharmacy owners,</li>
<li>The first are the ones who know they have had a breach</li>
<li>The later are the ones who have had a breach and don&rsquo;t know about it</li>
</ul>
How can I have a breach and not know about it?
<ul>
<li>Simple, has your pharmacy clerk ever given a patient another patient&rsquo;s medication?
<ul>
<li>That is a breach</li>
</ul>
</li>
</ul>
Can you give me examples of breaches?
<ul>
<li>Pharmacy is robbed and the will call bin is stolen</li>
<li>Pharmacy is robbed and the server is stolen</li>
<li>Staff pharmacist has a laptop stolen</li>
<li>Delivery driver has their vehicle stolen which is full of prescriptions to be delivered</li>
<li>Billing manager has a jump drive with patient files for billing to work at home and loses it on the bus</li>
</ul>
What do I do when a breach occurs?
<ul>
<li>First, don&rsquo;t panic</li>
<li>Get the facts</li>
<li>Complete a Potential Breach Evaluation and a Risk Assessment</li>
<li>Determine whether the breach is reportable or non-reportable to HHS/OCR</li>
<li>Document everything&nbsp;</li>
</ul>
What are OCR Desk Audits
<ul>
<li>Tested in 2016</li>
<li>Launched on January 1, 2017</li>
<li>Notification via U.S. Mail and Email</li>
<li>Also conducting no notice on-site inspections</li>
</ul>
What is the OCR asking for?
<ol>
<li>Notice of Privacy Practices (date must be after 07/01/2013)</li>
<li>Risk Analysis</li>
<li>Risk Management Plan</li>
<li>Disaster Recovery Plan/Contingency Plan</li>
<li>Annual Privacy and Security Assessments</li>
<li>Random Policies and Procedures</li>
</ol>
On-Site Inspections
<ul>
<li>Same as above, but in person</li>
<li>First question is to the person at your counter, normally your clerk</li>
<li>Can I have a copy of your Notice of Privacy Practice?</li>
<li>They have to know the answer and provide the NOPP</li>
</ul>
Penalties for Non-compliance
<ul>
<li>Fines up to 1.5 Million Dollars</li>
</ul>
&nbsp;Is there help available to pharmacies?
<ul>
<li>Yes, but you get what you pay for</li>
<li>You can buy a set of policies and procedures, but if you have breach, especially a reportable breach:
<ul>
<li>Will the consultant stay with you when you need them the most?</li>
<li>Will they charge you extra?</li>
<li>Will they provide the correct advice?</li>
</ul>
</li>
</ul>
How do you know how to pick a consultant?
<ul>
<li>Ask your peers</li>
<li>Ask hard questions about how they have handled client breaches and inspections</li>
<li>Do you get detailed answers from the consultant?</li>
<li>Do you referrals from multiple people?</li>
</ul>
CONTACT:&nbsp;Office: &nbsp;<a href="callto:724-357-8380">724-357-8380</a>&nbsp;
Website: &nbsp;<a href="http://www.rjhedges.com/">www.rjhedges.com</a>

In March of 2009, Todd S. Eury, launched the Pharmacy Podcast Show. Over the years, the Pharmacy Podcast has accumulated over 75,000+ listeners and subscribers and is the most popular and downloaded podcast about the Pharmacy Industry.

The Pharmacy Podcast Show transformed into the Pharmacy Podcast Network (PPN) in 2014 and will continue to collect the thought leading interviews with some of the most brilliant minds in Pharmacy with over 30 co-hosts. The PPN is a Digital Health Publication and Content Developing partner to the Pharmaceutical industry focusing on Specialty medications, pharmacy business supportive technologies, and industry trends.

The PPN is the world's largest network of podcasts dedicated to the pharmacy professional and industry insiders leading with our hosts interviewing dynamic people in the pharmacy industry making a difference for our profession, customers, and patients.

The definition of “Innovation” is: A new method, idea, product, or process. Processing, implementing, operating, or designing beyond the status-quo. Pharmacists are the HUB of Healthcare & the PPN is the Pharmacist's biggest fan. 

In March of 2009, Todd S. Eury, launched the Pharmacy Podcast Show. Over the years, the Pharmacy Podcast has accumulated over 75,000+ listeners and subscribers and is the most popular and downloaded podcast about the Pharmacy Industry.
The Pharmacy Podcast Show transformed into the Pharmacy Podcast Network (PPN) in 2014 and will continue to collect the thought leading interviews with some of the most brilliant minds in Pharmacy with over 30 co-hosts. The PPN is a Digital Health Publication and Content Developing partner to the Pharmaceutical industry focusing on Specialty medications, pharmacy business supportive technologies, and industry trends.
The PPN is the world's largest network of podcasts dedicated to the pharmacy professional and industry insiders leading with our hosts interviewing dynamic people in the pharmacy industry making a difference for our profession, customers, and patients.
The definition of &ldquo;Innovation&rdquo; is: A new method, idea, product, or process. Processing, implementing, operating, or designing beyond the status-quo. Pharmacists are the HUB of Healthcare &amp; the PPN is the Pharmacist's biggest fan.&nbsp;

Pharmacy Podcast Network

R.J. Hedges & Associates is the host of the Pharmacy Compliance Guide. 

At R.J. Hedges & Associates we treat our clients the same way we treat our employees: with respect, dignity, and honesty. We consider our employees and clients as members of the family. We founded our company on our strong beliefs and moral standards to make federal compliance obtainable, reasonable, and achievable for our clients. We strive to keep our clients informed of the ever changing healthcare regulatory environment by providing newsletters and bulletins to keep them up to date, webinars for clarification, and task lists to help manage requirements while still taking care of patients.

R.J. Hedges &amp; Associates is the host of the Pharmacy Compliance Guide.&nbsp;
At R.J. Hedges &amp; Associates we treat our clients the same way we treat our employees: with respect, dignity, and honesty. We consider our employees and clients as members of the family. We founded our company on our strong beliefs and moral standards to make federal compliance obtainable, reasonable, and achievable for our clients. We strive to keep our clients informed of the ever changing healthcare regulatory environment by providing newsletters and bulletins to keep them up to date, webinars for clarification, and task lists to help manage requirements while still taking care of patients.

Pharmacy Compliance Guide

The Pharmacy Podcast Network (PPN) is the world's largest network of podcasts dedicated to the pharmacy professional and industry insiders leading pharmacy care. We are proud to have gathered more than 40 different hosts interviewing dynamic people in the pharmacy industry making a difference for our profession, customers, and the patients we serve.

The PPN started in March of 2009 and has generated more than 2,000+ episodes publishing 6 to 7 days per week with over 140K+ listeners per month. The PPN was the first podcast to release continuing education for pharmacists in 2019 and was voted 'Healthcare Podcast of the Year' in 2022 by the Healthcare and IT Marketing Community (HITMC).

We're exploring the profession of pharmacy through audio. Pharmacists are our favorite Providers.

Pharmacy Podcast Network™ is a registered trademark

The Pharmacy Podcast Network (PPN) is the world's largest network of podcasts dedicated to the pharmacy professional and industry insiders leading pharmacy care. We are proud to have gathered more than 40 different hosts interviewing dynamic people in the pharmacy industry making a difference for our profession, customers, and the patients we serve. The PPN started in March of 2009 and has generated more than 2,000+ episodes publishing 6 to 7 days per week with over 140K+ listeners per month. The PPN was the first podcast to release continuing education for pharmacists in 2019 and was voted 'Healthcare Podcast of the Year' in 2022 by the Healthcare and IT Marketing Community (HITMC). We're exploring the profession of pharmacy through audio. Pharmacists are our favorite Providers.
Pharmacy Podcast Network&trade; is a registered trademark

HIPAA Breaches & Desk Audits What is a breach?  In simple words, the loss of patient protected health information, either printed or electronic.  How common are breaches within pharmacies?  There are two types of pharmacies and pharmacy owners,...

HIPAA Breaches & Desk Audits - Pharmacy Compliance Guide - Pharmacy Podcast Episode 399

Each day, more than 130 people die from opioid overdoses.

Opioids are a class of drugs that include prescription pain relievers like oxycodone. They also include illegal drugs like heroin. In 2019, 1.6 million Americans had an opioid addiction. This is also known as opioid use disorder. Yet effective medications—like buprenorphine, methadone, and naltrexone—are prescribed to only a fraction of people with opioid use disorder. Patients often receive such medications in an opioid treatment program. Methadone, for example, can only be given in a certified treatment program. Primary care physicians can apply for a waiver to prescribe buprenorphine. However, less than 10% of U.S. primary care providers have a buprenorphine waiver. Given the limited number of patients that each physician can treat, involving pharmacists in opioid treatment may improve access.

The Doctor Patient Forum’s Mission Statement is to advocate, educate, and defend the rights of patients, to protect all providers (including prescribers and pharmacists) who tirelessly work to treat their patients, and to bring awareness to the general public regarding restrictions upon medical providers. We are fighting for a return to individualized patient care instead of using guidelines and laws based on little evidence using arbitrary thresholds. Contrary to what has been said, we are not “industry funded.” We haven’t taken any money from pharma. We are not being paid to promote opioids. We are simply chronic pain and illness patients who are fighting as hard as we can to effect change in this broken system where the patient’s voice is non-existent.

For part 4 of the series, we're honored to have Ms. Bev Schechtman. Ms. Schectman is one of the founding members of Don’t Punish Pain Rally and is the VP of The Doctor Patient Forum. She grew up in northern New Jersey, and has lived in the Raleigh area in North Carolina since 2009. Bev has been married to Randy for 18 years, and has two teenage daughters, Emma, 17, and Livvy,13. She also has a 3-year-old Aussidoodle, Griffin.

Bev has been living with Crohn’s Disease and Psoriatic Arthritis for over two decades. She first contacted Claudia Merandi after being denied opioid medication while hospitalized for kidney stones in 2017.She was denied due to being a survivor of childhood sexual abuse. Bev is a passionate advocate for people with chronic pain and illness as well as those who have PTSD/ survived sexual assault/abuse. Bev has her B.A. in Psychology and hopes to get her M.S.W. in the near future. Bev is a voracious reader and researcher. She is passionate about understanding why pain patients are being mistreated so she can educate other patients and empower them to fight back. Bev hopes her advocacy work brings awareness to the anti-opioid zealots who are profiting off of punishing pain patients while pretending to care about those with addiction. She also believes strongly in Harm Reduction efforts.

Each day, more than 130 people die from opioid overdoses.
Opioids are a class of drugs that include prescription pain relievers like oxycodone. They also include illegal drugs like heroin. In 2019, 1.6 million Americans had an opioid addiction. This is also known as opioid use disorder. Yet effective medications&mdash;like buprenorphine, methadone, and&nbsp;<a href="https://en.wikipedia.org/wiki/Naltrexone">naltrexone</a>&mdash;are prescribed to only a fraction of people with opioid use disorder. Patients often receive such medications in an opioid treatment program.&nbsp;<a href="https://en.wikipedia.org/wiki/Methadone">Methadone</a>, for example, can only be given in a certified treatment program. Primary care physicians can apply for a waiver to prescribe&nbsp;<a href="https://medlineplus.gov/druginfo/meds/a605002.html">buprenorphine</a>. However, less than 10% of U.S. primary care providers have a buprenorphine waiver. Given the limited number of patients that each physician can treat, involving pharmacists in opioid treatment may improve access.
The Doctor Patient Forum&rsquo;s Mission Statement is to advocate, educate, and defend the rights of patients, to protect all providers (including prescribers and pharmacists) who tirelessly work to treat their patients, and to bring awareness to the general public regarding restrictions upon medical providers. We are fighting for a return to individualized patient care instead of using guidelines and laws based on little evidence using arbitrary thresholds. Contrary to what has been said, we are not &ldquo;industry funded.&rdquo; We haven&rsquo;t taken any money from pharma. We are not being paid to promote opioids. We are simply chronic pain and illness patients who are fighting as hard as we can to effect change in this broken system where the patient&rsquo;s voice is non-existent.
For part 4 of the series, we're honored to have Ms. Bev Schechtman. Ms. Schectman is one of the founding members of Don&rsquo;t Punish Pain Rally and is the VP of The Doctor Patient Forum. She grew up in northern New Jersey, and has lived in the Raleigh area in North Carolina since 2009. Bev has been married to Randy for 18 years, and has two teenage daughters, Emma, 17, and Livvy,13. She also has a 3-year-old Aussidoodle, Griffin.
Bev has been living with Crohn&rsquo;s Disease and Psoriatic Arthritis for over two decades. She first contacted Claudia Merandi after being denied opioid medication while hospitalized for kidney stones in 2017.She was denied due to being a survivor of childhood sexual abuse. Bev is a passionate advocate for people with chronic pain and illness as well as those who have PTSD/ survived sexual assault/abuse. Bev has her B.A. in Psychology and hopes to get her M.S.W. in the near future. Bev is a voracious reader and researcher. She is passionate about understanding why pain patients are being mistreated so she can educate other patients and empower them to fight back. Bev hopes her advocacy work brings awareness to the anti-opioid zealots who are profiting off of punishing pain patients while pretending to care about those with addiction. She also believes strongly in Harm Reduction efforts.

Where's the Patient's Voice in Evidence-based Treatment & Research? | Pharmacist and Physician Opioid Collaborative

Pharmacists Answering the call | Pharmacy Podcast Nation

Ila M. Saunders, PharmD, BCOP, co-founder and leadership team member of the #PharmGradWishList interviews Ja’Miera Stuart, PharmD, #PGWL sponsee and winner of a large item crowdfunding campaign to support moving and relocation expenses to begin her PGY1 pharmacy residency.

Dr. Stuart has been interested in a career in pharmacy since high school when she began pre-pharmacy coursework. As a graduate of Florida A&M University, Dr. Stuart truly embraced the role of the pharmacist as a healthcare practitioner and ambassador. During her involvement in Student National Pharmaceutical Association, Dr. Stuart rallied and amplified the voices of underrepresented minorities. Now, Dr. Stuart began her career and continued her education as a pharmacy resident at Howard University Hospital, serving a pivotal patient population in the DC metro area.

Dr. Stuart is grateful for the generous outpouring of support from the pharmacy community who have and continue to help her achieve her goals and aspirations. She remains passionate about supporting opportunities, like those she has received, to continue diversifying pharmacy and healthcare.

To support other aspiring pharmacists, like Dr. Stuart, please follow more of her story on her instagram @morph_rx and you can find more information at pharmgradwishlist.org! 

Ila M. Saunders, PharmD, BCOP, co-founder and leadership team member of the #PharmGradWishList interviews&nbsp;Ja&rsquo;Miera Stuart, PharmD, #PGWL sponsee and winner of a large item crowdfunding campaign to support moving and relocation expenses to begin her PGY1 pharmacy residency.
Dr. Stuart has been interested in a career in pharmacy since high school when she began pre-pharmacy coursework. As a graduate of Florida A&amp;M University, Dr. Stuart truly embraced the role of the pharmacist as a healthcare practitioner and ambassador. During her involvement in Student National Pharmaceutical Association, Dr. Stuart rallied and amplified the voices of underrepresented minorities. Now, Dr. Stuart began her career and continued her education as a pharmacy resident at Howard University Hospital, serving a pivotal patient population in the DC metro area.
Dr. Stuart is grateful for the generous outpouring of support from the pharmacy community who have and continue to help her achieve her goals and aspirations. She remains passionate about supporting opportunities, like those she has received, to continue diversifying pharmacy and healthcare.
To support other aspiring pharmacists, like Dr. Stuart, please follow more of her story on her instagram @morph_rx and you can find more information at&nbsp;<a href="https://www.listennotes.com/podcasts/pharmacy-podcast/jamiera-stuart-brighter-WaVAb4oIEGp/pharmgradwishlist.org">pharmgradwishlist.org</a>!&nbsp;

HIPAA Breaches & Desk Audits - Pharmacy Compliance Guide - Pharmacy Podcast Episode 399

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