Source: https://www.waruralhealth.org/sept201888
Timestamp: 2019-04-20 20:18:00+00:00

Document:
Welcome to the September 2018 issue of the Washington Rural Health Association e-Newsletter. Inside this issue you will find news and information from the Executive Director and board of directors, members, and community partners from across the state of Washington.
The Washington Rural Health Association (WRHA) is a nonprofit, grassroots, member-driven organization that advocates for empowering all Washingtonians to advance their quality of life, their well-being and their access to excellence in rural health care. For more than 30 years, the WRHA has been serving rural communities by advancing and publicizing rural health issues and seeking to solve rural health care challenges. But, to continue this important work, we need your help.
WRHA is primarily a volunteer organization, led by one paid employee, the Executive Director, and a volunteer Board of Directors. However, funding for this ED position is minimal and may not be sustainable in the next year.
Quality leadership is essential to achieving the WRHA’s mission of supporting our rural communities. In the past two years, we have made great strides in improving health care for Washingtonians and we want to sustain this momentum.
Advocacy and representation - monitoring and reporting legislative and regulatory issues relating to rural health.
Board and Executive Director developed a legislative and policy agenda to be shared with legislature, congressional delegation, and others. Added a legislative tab to WRHA website to keep members informed and encourage them to advocate for rural.
ED serves on following committees: Rural Health Professional Loan Repayment & Scholarship Program Committee, Emergency Cardiac and Stroke Technical Advisory Committee, NRHA Rural Health Congress and State Health Improvement Plan Steering Committee.
ED participated in FOUR rural health legislative panels to discuss the repeal and replace of Affordable Care Act and what the repeal would mean for Medicaid expansion states.
Convened ONE Rural Health Listening Session, purpose to provide input on how we can foster collaboration between the health and community development sectors to improve our economic, social and built environment, including serving the needs of low- and moderate-income individuals and families.
Monthly communications about rural healthcare scholarships, funding, educational, and other networking opportunities.
Increased exposure and promotion equitable access to appropriate and comprehensive health services for rural Washingtonians by utilizing social media outlets: Facebook, LinkedIn and Twitter as well as WRHA e-Newsletter.
Increased organizational membership from 98 to 180 total members, broadened membership to include more students, regional groups, and businesses.
Increased organizational sponsors to WRHA to include: Wilderness Medical Staffing, Amerigroup, Deaconess Hospital | MultiCare Health System, Wipfli CPA and Consultants and Coulee Medical Center.
Applied for 9 grants and awarded 7, totaling $34,850.
As Executive Director and member of a remarkable Board of Directors, my hope is the Washington Rural Health Association continues to find ways to help this great community soar. Believe me, the best is yet to come – but we can’t do it without you.
All money generated through our campaign will be used to provide much needed funding to support the Executive Director position and enable us to continue our mission to help improve health for the people living in rural communities. In addition, funds will help support travel, receptions and other support for our advocacy and legislative activities.
You can send in your donation, either by check, or by demand draft, drawn in favor of WRHA. You may also donate using your debit/credit card through our website www.waruralhealth.org, or contribute using campaign link: gofundme.com/support-wrha-operations.
Your donation of as little as $10 can help the Washington Rural Health Association unite people, communities and organizations to strengthen rural health in Washington State. And you will be demonstrating your commitment to rural health care while increasing your exposure to Washington’s hospitals, health systems, rural health clinics, public health departments and many other rural health organizations.
Finally, research shows that when members of an association get involved at the board level or on committees their personal sense of satisfaction increases markedly. Are you looking for something worthwhile to do? Would you like to increase your own sense of personal satisfaction? WRHA needs more members.
Thank you for your passion, your courage and your support. It makes a difference!
Last month WRHA Board President Sandy Brecker, attended the National Rural Health Association Leadership Conference (formerly known as the Skill-Building Workshop. It provides an opportunity for state rural health association leaders to learn from each other and develop skills for achieving the goals of their own state association. 40 representatives from State Rural Health Associations across the country attended this event in Washington D.C.
The workshop was an enlightening and valuable experience for Sandy as I listened to her recount all of the information presented and how rural health associations are managed in other states. I was able to absorb some great ideas for our organization suggested by NRHA staff. Sandy, wanted to share some of the things she learned with you. First, the NRHA would like an update from the rural associations on what we may see in our communities that is working related to opioid crisis. They need your success stories to share! They are actively involved as well to help with working solutions on the opioid crisis.
The NRHA suggested that organizations who have a Twitter account to utilize it to speak to our legislature publicly as they will respond. Follow your senators and representatives as they use it to directly engage with their constituents. Make sure to tag @ruralhealth in your tweet as the NRHA will retweet to make message stronger.
They suggested that the WRHA host a day at the state office by coordinating with a legislative clerk. It allows the organization to spread the message as the representatives as they stop by.
As an organization or member if you have a positive story, especially where a state representative is in support of the initiative write a letter to the local paper or radio station mentioning the representative. It gains positive exposure for our communities.
The NRHA has a library of webinars that are tailored to individual states. The WRHA will be able to access those and make available to our members.
Medicaid reimbursement to rural clinics and hospitals is a problem for virtually every state in the country. Medicaid is a health entitlement program for poor and disabled people and is shared between states and the federal government. While our whole nation is suffering through an economic downturn most individual states have also been scrambling for the last two years or so to get their spending down to match plummeting revenues. Washington is no exception as our situation became so dire cutting into important human services, including Medicaid occurred.
It was heartening to hear the NRHA say how important rural is. Rural is an entity unto itself with its own unique qualities and issues. The Washington Rural Health Association (WRHA) is working hard on your behalf. We, the State Office of Rural Health stand shoulder to shoulder with administrators, providers, and other citizens to maintain and improve our rural health care system.
As a member please follow the WRHA on Twitter @WARuralHealth, on LinkedIn (Washington Rural Health Association) and Facebook (WA Rural Health Association). Together we have the power to be heard and make our message stronger.
I attended the conference and was nominated to be on the board.
I am passionate about improving rural health accessibility and quality for patients living in the rural portions of Washington.
It is important to me because I lived in rural Washington as a child and unfortunately, did not have good quality healthcare.
How engaged our board members are.
Getting to work with amazing and talented people.
I think the most challenging issue is lack of funding to help recruit and retain quality health care providers into the rural areas.
How active we are at the state level.
I would only change our membership, I love working with our association. I think we should partner with like associations to leverage our work and membership base.
None others at this time.
That I used to be a State Trooper.
Increase partnerships with like organizations to maximize our efforts. Increased membership.
The Useless Bay Women's Golf Association set a new record with their Cancer Care Tournament and Cancer Awareness Week, raising over $50,000 to support oncology services at WhidbeyHealth. The golfer's held the annual tournament in June. "These women are amazing!" says Helen Taylor, Executive Director of the WhidbeyHealth Foundation. "Every year, this event grows and serves more people needing cancer care here on the island."
Funds raised will be used to purchase cooling technology that helps patients who need chemotherapy prevent hair loss during treatment. Event Chair, Ellen Sargent, and her mighty team of volunteers made sure that the 80 golfers and 110 luncheon guests had a day to remember. "I want to thank everyone who helped to make this event successful," says Sargent. "We couldn't do it without our donors and all the sponsors who support us every year!"
This year's event included games at the men's tournament and a sock-hop on the Saturday night following the tournament, that was enjoyed by more than 150 club members and guests.
He specializes in augmentative and alternative communication and brings experience in treating common speech-language symptoms, including difficulty understanding language, following directions, difficulty producing individual sounds and frequent abnormal disruptions in the flow of speech. When asked about his approach, John responded, "I focus on play-based therapy to capture a child's attention and make memories that will extend beyond the therapy session. These memorable moments support learning and retention. They are essential to a lasting rehabilitation."
The speech-language pathology program is an example of the Spokane Shriner's Hospital staff's continued efforts to improve the lives of children. If you know a child who would benefit from the speech-language pathology program, please contact our intake staff at 888-895-5951.
For more information visit: www.cmccares.org.
Mid-Valley Hospital & Clinic has signed an affiliation agreement on July 12, 2018 with Washington State University's School of Medicine. The clinical partnership will allow Mid-Valley to provide preceptorships, or mentored experiences with licensed physicians for on-the-job training and supervision. In the medical student's third year of education, Mid-Valley Hospital & Clinic will be a clinical site for longitudinal integrated clerkships (LIC), a model of long-term clinical education where the same students continue to return to the same rural location. "As an alumni of WSU I'm very excited to have our hospital partnering with the Elson S. Floyd School of Medicine. The coordination between the two entities can lead to improved medical care in our rural communities. Go Cougs!" says Alan Fisher, CEO, FACHE. The preceptorships and LIC's allow a medical student to learn the foundational sciences of medicine combined with immersion and development of the fundamentals of clinical practice. This method allows the student to follow patient cases all the way through and develop familiarity and relationships within the Omak area. WSU's website states that "LICs are a relatively new and innovative concept in clinical learning".
The Elson S. Floyd College of Medicine is proud to be one of a handful of U.S. medical schools that has adopted the LIC as its primary clinical training model for all students. Advantages include retaining empathy, improving recall, and building strong relationships with patients and preceptors. Elson S. Floyd is a brand new college of medicine founded in 2015, with the first cohort beginning in August of 2017. Mid-Valley Hospital "Redefining exceptional service through compassionate care to our neighbors".
The Center for Connected Medicine* recently released its publication The Rise of Genomics in healthcare that provides an overview of the growth of this exciting industry destined to turn the current medical model of care on its head. Since the first mapping of the human genome nearly a decade ago, the science of genetics has grown exponentially making genetic testing results readily available to the average consumer at an affordable price and in a shorter timeframe. From individuals looking to connect with their heritage to health-conscious souls seeking to learn about whether or not they have inherited a defective gene that could predispose them to a certain illness, healthcare providers are also eager to begin using genetic test results to provide individualized medical treatment and care. This white paper discusses some of the hopes and challenges to making this a reality.
Data storage- The sequencing of one tumor creates two terabytes of data (equivalent to 34,000 hours of music) so healthcare infrastructure capacity will need to be managed. Also, integrating genetic test results with the healthcare provider’s electronic medical record will present challenges.
Privacy- The majority of consumers are concerned about who has access to their genetic data and cyber hacking of this personal data is a real concern.
Consent- Consumers want to be in control of their health data and consent must be obtained for the initial and subsequent genetic testing and the sharing or release of the results with healthcare providers.
Provider education- Most primary care physicians are not experienced in interpreting the results of genetic sequencing and specific training is needed during medical school, residency, and ongoing continuing education.
Liability- Lab errors in gene sequencing and/or interpretation of results can lead to misdiagnosis and treatment errors exposing providers to malpractice claims.
*The Center for Connected Medicine at the University of Pittsburgh, in partnership with leading technology firms, provides a platform for thought leadership and innovation by connecting advanced technologies and world class healthcare expertise to develop new models of delivering healthcare in today’s rapidly changing environment. For more information visit www.connectedmed.com.
Central Washington Hospital, a 198-bed a general medical and surgical facility in Wenatchee, Wash., plans to close its 22-bed transitional care center for aging patients, The Wenatchee World reported.
Shriners Hospitals for Children in Spokane, Wash., is reducing its workforce by about 10 percent as it transitions to an outpatient-focused micro hospital.
Washington State has been awarded another HRSA grant for the Federal-State Loan Repayment Program (FSLRP). We applied for, and were awarded, the maximum amount of $1 million per year over four years. For more information, please see the announcement.
Scott Graham has been appointed CEO at North Valley Hospital, shared with Three Rivers Hospital through an interlocal agreement. Former North Valley Hospital Interim CEO John McReynolds will return to his prior position of chief operating officer of the hospital. Welcome to the position, Scott!
The purpose of this update is to keep stakeholders apprised of news and updates associated with the Rural Health Multi-Payer Transformation Project. Below are documents that list key milestones or activities that have occurred over the last three weeks.
Short term medical plans coming to WA?
The ACA essentially got rid of "short term limited duration" (STLD) health plans. Under the ACA, plans had to be one year long with a minimum set of benefits that fell into a set actuarial range - all things STLD plans don't do. However, as a result of a Trump Administration rule, the OIC is now preparing a rule to re-allow such plans into the state with a set of relatively narrow provisions. The idea of STLD plans is they have reduced benefits and reduced costs. They tend to attract healthier people and thus undermine the risk pool consumers leave behind (usually the individual market).
DON'T MISS YOUR OPPORTUNITY! The Sentinel Network data submission window has been extended by one week, but ends Sept. 10.
High turnover? Poor retention? What trends are you noticing?
What types of vacancies are getting harder to fill and why?
New skills? New roles? What might help address these needs?
How have priorities around your workforce changed?
Use the Health Workforce Sentinel Network to share your organization's healthcare recruiting hurdles, common skill gaps, and other workforce challenges.
Healthcare providers have used the Sentinel Network to tell about the occupations and skills they need—but can’t always get. Feedback on changing roles helps Washington’s education and training programs retool to reflect these changes and provides input to influence policy changes. Check the findings dashboard to view what Sentinels have said to-date.
The details you provide, including specific recruitment challenges, are kept confidential.
Registration and updates coming soon!
State of Reform is hosting their annual eastern Washington Conference on Thursday, September 13, 2018. NWRHC attendees get a 20% discount on attendance. To get your discount, enter code EWU at checkout.
Good, experienced Nurses are expensive and hard to come by. With scarcity comes increased costs.
1. Nurse Placement Costs Icon has been in the business of recruiting foreign Nurses from the Philippines since 2002; and, we have placed over 1,550 foreign Nurses to U.S. careers. The Recruitment costs for a foreign Nurse does not just include the Recruiter fee. The real costs of recruiting a foreign Nurse are: Recruiter fee in USA and Foreign Country, Interview costs, Legal fees, Visa fees, including Priority Processing, Testing fees: NCLEX, IELTS and CGFNS VisaScreen review, testing and certification fees, Embassy fees, Visa Medical Physical fee, Courier and ''FedEx'' fees, Insurance, Plane fares in the foreign country and to America from half-way around the globe, Hotel, meals and ground transportation costs for the Nurse, State Board of Nursing licensure, two(2) or three(3) months of furnished housing for the Nurse, and arrival stipend to get the Nurse to his/her first paycheck.
2. Employment Contract: The foreign Nurse signs a 3-year employment agreement with the healthcare employer that contains a substantial penalty should the foreign Nurse's early termination or abandonment of the employment agreement.
3. Demand and Supply Recruiting Nurses is not cheap. Factors that will affect foreign Nurse recruitment costs include that due to the Nurse labor pool and visa availability being small and demand being very high or if specialized skills are necessary for the job.
4. Permanent Placement RN Costs Vary The all in costs of recruiting a foreign Nurse can range from $20,000 to $45,000, the cost is mostly dependent on specialty, experience and availability, according to an article in the September 2007 "Online Journal of Issues in Nursing." Recruitment, selection, orientation and training are all costs that must be considered when an organization hires a new Nurse. Because of the total costs of recruiting a U.S. licensed foreign Nurse, it is mandatory that the healthcare employer insist on a 3-year employment contract inorder to amortize these costs over time.
5. Icon's Total Costs Of Recruiting A Foreign Nurse. Icon's current cost pegged at $20,000 including everything detailed in #1 above.
a) They're kidding or playing ''fast and loose'' with the truth.
b) They do not have the experience to know the real costs.
c) They are playing the ''onion game'' with you. They quote low and after the recruitment is active they peel away another layers of costs.
d) Ask them what their price quote includes. If the quote does not include the Nurse Placement Costs from #1 above, get ready for some serious surprises down the road.
The town of Chelan – 3900-4500 population, 1620 occupied houses, 650 households containing someone over 60, 20-25% Hispanic; Manson – 1500-1800 population, 570 households, 250 households containing someone over 60, 35-45% Hispanic; Chelan Falls – 350 population, 100 households, 33 households containing someone over 60 in residence, 50% Hispanic. From this data, the need for services to seniors in both English and Spanish is apparent.
The CVCN program evolved out of a Senior Living Initiative in the community that was looking at concerns around being able to maintain a residence in the area while aging. Two task forces developed: The Campus of Care task force is looking at construction of facility living for multiple care levels, and The In-Home task force which has been focusing on gaps in available services and program planning to fill the gaps to allow seniors to age in place. The CVCN Program came from this task force, and I am honored to have been the nurse for the past year.
There is now a community nurse available to do preventive and educational home visits to the vulnerable and frail adults of the Chelan Valley. While the majority of clients are seniors, the range in age has been from 22 to 96. Grant and donation funded, with the goal of assisting people to access resources to allow them to remain in their homes, there is no charge for the service.
The program focus is on safety and prevention of adverse health incidents in the home. The nurse is able, for instance, to assist with understanding of medications and treatments perhaps because of a recent hospital discharge or a change in condition. Referrals come from physicians, discharge planners, case managers, family members, pastors, friends, and clients themselves. The program is designed to supplement, not compete with, existing support programs. The program also offers community blood pressure screenings and submissions to local newsletters on preventive health issues. As of August 15th, there are 186 clients in the database and 50 of them are receiving home visits.
With a little over a year in action, there have been so many wonderful success stories. As is the case in-home care, there are almost as many solutions to problems as there are different homes. A frequent and often relatively easy intervention is with medications. This can involve teaching about medications, assisting with organization, discarding of outdated medications and communicating with the physician with regards to what is actually being taken at home. Other activities include: collaborating with service clubs to install grab bars and ramps, signing up for assisted transportation, helping families locate an in-home caregiver, teaching about chronic disease process, encouraging participation in Senior Center activities and meals, referring to volunteer companion services, referring to physician for referral to home health and or hospice, facilitation the beginning of end of life discussions, assisting families in the difficult transition from home to supervised care, and always knowing and collaborating with other service and healthcare providers on the team.
As a registered nurse with over 30 years of home visiting experience ranging from mother baby visits to hospice, this is a wonderful program. In assessing issues for a patient, I have always found that home-based assessments are the most helpful, informative and efficient ways to obtain answers. This is probably the most rewarding position of my career, and also the most challenging. For a year I have been on my own with program development, fundraising, public relations, and delivery of services. Recently there is a volunteer advisory board that has stepped up and we are looking to expand the program because of demand and to roll out more comprehensive services for the Spanish speaking community. We are looking to double the RN hours and are actively recruiting a nurse. This position is very flexible and would attract either a nurse wishing to slow down an active career and/or a nurse actively parenting who can work around school and child rearing schedules.
Please contact me for more information: Michelle Jerome RN, BSN at [email protected] or 509-679-9059.
The CMS Emergency Preparedness Rule Part I: Does the Rule Impact Your Health Care Organization?
In 2016, the Centers for Medicare & Medicaid Services (CMS) finalized a rule requiring health care providers that participate in Medicare and Medicaid to meet specific emergency preparedness requirements. CMS created the rule to help ensure facilities are prepared to meet the needs of patients during natural disasters or man-made emergencies.
Not complying with the rule will result in a health care provider losing its Medicare and Medicaid reimbursement, so it’s important to know if you’re affected. In part one of this two-part blog on complying with CMS’s rule, we’ll go over which provider types are impacted and what the rule’s main requirements are.
Hospitals, critical access hospitals and long-term care facilities are required to have emergency and standby power systems that maintain temperature; emergency lighting; and fire detection, extinguishing and alarm systems.
Outpatient providers and suppliers are not required to have policies and procedures for the provision of subsistence needs.
Home health agencies and hospices are required to inform officials of patients in need of evacuation.
Risk assessment and emergency plan: Develop an emergency plan based on a risk assessment. This risk assessment must be performed using an all-hazards approach focused on capacities and capabilities. The emergency plan must be updated annually.
Policies and procedures: Develop and implement policies and procedures that cover a range of issues, including subsistence needs, evacuation plans, procedures for sheltering in place and tracking both patients and staff during an emergency. These policies and procedures must be updated annually.
Communication plan: Develop and maintain a communication-focused plan to ensure your organization can coordinate patient care within your facility, across health care providers, with state and local public health departments and with emergency systems. This plan must be reviewed and updated annually.
Training and exercise: Your organization must develop and maintain training and testing programs and participate in two difference exercises per year. One exercise must be community-based, while the other must be either facility-based or a tabletop exercise.
These four core standards were developed because CMS found that regulatory requirements did not comprehensively address the need for contingency plans, proper training of staff and appropriate communication with other health care systems or with affected cities and states.
Stay tuned for part two on complying with the emergency preparedness rule, when we dive deeper into the four core requirements and what they mean for your organization. If you would like to learn more about how your health care organization can comply with the rule, contact Wipfli today.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-09-08.html, accessed March 1, 2018.
The Office of Rural Programs is a little over one year into its history and it continues to grow and reach out to the WWAMI region to increase its impact. Our flagship program, RUOP (Rural Underserved Opportunities Program) remains robust after 29 years even as the stipend supporting students was discontinued through the new curriculum adopted in 2015. The RUOP team comprised of Toby Keys, Brenda Martinez, and Sarah Lee along with help from RUOP mentors, Jimmy Wallace M.D., Molly Hong M.D., Kim Kardonsky, M.D., Stacey Morrison, Larry Kirven, M.D., and Neil Sun Rhodes M.D., has been working over the summer to help students with their clinical exposure as well as their Triple I projects. Well over 100 community physicians have helped to create excellent exposures for these students.
TRUST (Targeted Rural/Underserved Opportunities Track) is approaching its 10-year anniversary. It continues to attract students with significant commitments to disenfranchised populations and more graduates of the program are starting to complete their residency training. We look forward to their return to the region and hope to see an impact beginning to manifest.
At this time the WRITE program (WWAMI Rural Integrated Training Experience) is celebrating 22 years of existence and now has 39 sites which are active and sought after by students. Nationally, this longitudinally integrated method to medical education has been lauded as an approach which is helpful and helps to maintain empathy. We have needed to develop two waves of students going through this program and are exploring the development of a third wave.
Additionally, the Olympia Longitudinally Integrated Clerkship is being wrapped into the Office of Rural Programs. This small city clerkship has been successfully running for the last 5 years and has provided an excellent learning environment for a number of medical students.
Finally, the WWAMI AHEC was awarded a $3 million grant by the U.S. Health Resources and Services Administration to fund the WWAMI AHEC Scholars program, a two-year, interprofessional and nationally-recognized certificate program that emphasizes a team-based approach to addressing health disparities. Faculty from the UW School of Medicine teamed up with the WWAMI Area Health Education Center (AHEC) Program Office and its regional Centers in Washington and Idaho to develop a program, which emphasizes inter-professional and experiential learning.
In this program students participate in two interprofessional courses. Topics cover practice transformation in team-based underserved settings, behavioral health integration, rural health, health equity and other emerging topics in underserved care. Additionally, they visit an urban underserved or rural healthcare setting, and participate in 40 hours of experiential/community training through a community project or service learning, and take part in a networking event with potential employers.
The WWAMI AHEC Scholars program launches in September 2018!
As some of you know, RUOP (Rural/Underserved Opportunities Program) has been a successful component of the UW School of Medicine for the past 32 years. This summer, more than 50 volunteer faculty from across the WWAMI region hosted UW medical students for their four-week RUOP rotations. Additionally, several volunteer faculty members also supported the community engagement projects completed by students during their RUOP rotations, and helped the students think through the impact physicians make on a community, and guide their reflections. In this article, we asked two of our faculty to share their experiences as RUOP mentors.
Molly Hong, M.D. has been a rural family physician in Port Townsend, Washington, for more than a decade providing full scope family medicine. She assists with UWSOM’s TRUST program (Targeted Rural Underserved Student Track) and by extension, RUOP and WRITE (WWAMI Rural Integrated Training Experience).
“Part of maintaining balance and perspective for me has always been exposure to students—in particular their passion, intelligence and innocence. It’s hard to be jaded when you are face-to-face with all the same energy and enthusiasm you had when you were at that stage of training,” says Dr. Hong.
It is clear that mentoring students has added value to our teaching colleagues. Certainly, it takes time, but the value of the interchange with our developing physician leaders is substantial. Their continued engagement speaks to the personal enrichment one can achieve by helping guide students through their training.
Standing up and running a rural Health Insurance Portability and Accountability Act (HIPAA) security program is often delegated to an information technology or clinic manager with limited HIPAA exposure. Our previous two articles focused on framing and resourcing a program; this writing will build on that foundation with practical actions that will help demonstrate compliance with Health and Human Services (HHS) requirements that are derived from federal law. The first thing a HIPAA Security Officer standing up or refreshing a program should do is start a compliance assessment using the (free) 2016 Office of Civil Rights Audit Protocol information, provided by HHS, at: www.hhs.gov/hipaa/for-professionals/compliance-enforcement/audit/protocol/index.html.
Parse the Audit Type column citations that list “Security”. Confirm that a citation belongs to theSecurity Rule by referring to its corresponding Section column; the information should begin with: §164.308, §164.310, §164.312, §164.314 or §164.316.
Select a single citation relevant to the Security Audit Type and copy the following columns into a word-processing (e.g. Word) document: Established Performance Criteria and Audit Inquiry. Note whether the citation has an “R” for Required, or an “A” for Addressable (note that Addressable does not mean optional) and annotate this information on your document.
Read and record answers to the Audit Inquiry column onto the document. Note “yes” or “no”whether your organization can or cannot produce artifacts that support the questions (e.g.policy and procedures, records of completed actions, etc.).
The 2016 Audit Protocol demonstrates how HHS expects Covered Entities and Business Associates to practically implement approximately 80 HHS citations AND includes the Security Rule language, so following this article’s guidance also accomplishes Security Rule familiarity. As the Audit Protocol is quite a bit of work, tackle as many citations per month as is reasonable; try to do at least one each week if the organization has never completed a risk assessment or performed this compliance assessment process.
The output of the compliance assessment is a gap analysis that can be used as the input to the Security Rule-required security risk analysis, listed under §164.308(a)(1)(ii)(A), Risk Analysis. Alternatively, a risk analysis can be completed using the Security Rule as the framework, against an accepted risk analysis methodology (e.g. NIST SP800-30, etc.) and not require a gap analysis as a prerequisite. A gap analysis can also partially fulfill the §164.308(a)(8) Standard, Evaluation.
Please reach out to the author if you’d like a complimentary Audit Protocol template document – with the understanding that no sales person will call or put you on a list if you request one.

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