Meeting & Agendas

Approved by committee

ACC HIPAA task force will change from reporting to the Shared Governance of Council to the Administrative Services Council under Environmental Health and Safety. Decisions/Actions: Until the approval for the move Mike Midgley, Vice President of Workforce Education and Business development will continue to receive the Annual HIPAA Report.

To Be Announced

Approved by committee

A. Report on College safety audit Discussion: Safety Audit conducted at the College in the fall 2007 semester did not address HIPAA related issues on privacy and security. A Safety Officer position has been put into the Master Plan by EHS and once that position is funded, a College wide process will be developed. Decisions/Actions: No recommendations from the Crisis Management Team for HIPAA. Follow-up Items >Continue to receive update from Crisis Management Team. Person Responsible: Becky Cole, Deadline None >Continue to receive information on District Wide Security Audit Person Responsible: Becky Cole, Deadline None

B. Compliance audit - schedule Discussion: The committee agreed that the committee should continue a system of HIPAA compliance audits. Suggestions included using the schedule of Internal Program Review. Other thoughts: Department Checklist Department Chair Compliance responsibility Violations and violation reviews Decisions/Actions: Annual Compliance Audit will be conducted electronically. P. Recek will draft an Annual Checklist that can be completed online and submitted to the HIPAA chair. P. Recek will draft a version and will send to committee for review and discussions. Audit form will be sent to Directors/Department chairs with a completion time at the end of the fall semester. The February Meeting will report on results. Final Draft to be presented to Department Chair at Spring Department Chair meeting. Follow-up Items >Electronic Annual Checklist draft for review and revision by committee. Person responsible: Pat Recek. Deadline: Fall 08 >Report on recommendations for Annual Review. Person responsible: Department Chair. Deadline:Fall 08. >Review submitted checklist electronically. Person responsible: Committee Members. Deadline: Fall 08 >Revisions made to checklist. Person responsible: Committee Members. Deadline: November 08. >Final Draft presentation. Person responsible: Pat Recek. Deadline: Spring 09.

Discussion: Handout – copy of email from Robert Rogers – Subject: Health Information form fitness trainer program, four pages. Revised Minutes from 04 Other Health Science Program’s Health Report Forms Self Disclosure De-identified forms from other programs Programs with paid/volunteer clients Decisions/Actions: Robert Rogers and Pam Soto revise KINE form Committee to review final draft from Pam Soto and Robert Rogers HIPAA approval of KINE Health Information form Follow-up Items: >Revised Kinesiology form. Person responsible: Pam Soto/Robert Rogers, Deadline: none. >Report on Results of Kinesiology Form. Person responsible: Committee, Deadline: none. >Final approval of KINE Health Information Form. Person responsible: Committee. Deadline: none.

Discussion: Student’s patient data in assigned unit Printed material/Image material Identifiable patient information Definition of de-identification Self disclosure Removal of patient information from printed material Identifiable patient information removal from unit by student/staff Decisions/Actions: Amend Education Training (power point on slide #27) to read No identifiable data can be removed from any assigned clinical placement area. Follow-up Items >Change power point slide #27 with amended statement. Person Responsible: Kirk White. Deadline: none

Discussion: Student incident –ADN student removed 27 pages of non-de-identified patient data from a clinical unit, even after several attempts by faculty to get student to shred the information. The issue was initially brought to the instructor’s attention by a unit ward clerk who noted excessive printing by student. Student was withdrawn from the program for unprofessional conduct. Student met with a counselor to discuss options for appeal and was guided to the grade appeal process. No further contact from student at the time of this meeting. Student self disclosed some health issues to a faculty member via email. The faculty forwarded the original email with her response to the Department Chair and another faculty who were not recipients of the original email. Decisions/Actions: The Dean reeducated the faulty regarding the possibility of HIPAA violations and faculty acknowledge the need to be more careful in relaying information about students.

None at this time