Essay on Task 4

804 Words4 Pages
Task 4 Sarah Phillips

Willow Bend Hospital’s compliance does indeed have multiple deficiencies and is in need of review as many were updated in 2009 and 2010. All information on deficiencies would be found on the latest updated version of the Joint Commission Information Standards. This should be located within the Corporate Compliance/Risk Manager’s office. As this information is not currently available to this writer without a subscription and fee, I must use the information available to me. So expansion and explanation of policy details are limited.

In 2010, the policy addressing terminology and abbreviations was integrated into the Information Management standards as elements of performance 2 and 3 under IM.02.02.0 by
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The Corporate Compliance/Risk Manager should also collaborate with department directors, Administration, and legal counsel to make sure appropriate actions for violations is upheld. Risk Management should also maintain HIPAA specific documentation a minimum of six years or as Joint Commission deems.

Department Directors should plan for employee education and training regarding privacy and confidentiality in cooperation with Staff Development. The directors should also monitor for compliance within their departments. The Staff Development department should be in charge of coordinating orientation, annual reviews, and periodic education and training. The Medical Records Director should develop an audit process to monitor compliance.

Knowledge-based information policy is found in Standard IM.03.01.01. Access of availability should be all the time, 24 hours a day, and 7 days a week. The HIM Manager should maintain information on knowledge-based information and the IT department should maintain electronic access.

An outside business can dispose of protected health information by purging or destroying electronic media. This is covered in 45 CFR 164.308(b), 164.314(a), 164.502(e), and 164.504(e). HHS HIPAA Security Series 3: Security Standards – Physical Safeguards is a good source for more information. The Medical Records Director should maintain documentation with all

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