How to Answer Newly Hired Director Questions (Complete Guide)

Understanding this question requires applying core subject principles.

What This Question Is About

This question relates to newly hired director and requires a structured academic response.

How to Approach This Question

Break the problem into smaller parts and analyze each logically.

Key Explanation

This topic involves newly hired director. A strong answer should include explanation, application, and examples.

Original Question

You are the newly hired HIM Director and facility privacy official (FPO) for San Jacinto Hospital. You are trying to assess the facility’s HIPAA security risk. You cannot find policies, procedures, or any other documentation. Hospital administrators are busy preparing for an upcoming accreditation survey and have not had time to assist you. HIPAA security breaches have been averaging ten per week. You decide to take a proactive approach by meeting with key hospital leaders and conducting a HIPAA security risk assessment. You met with the Facility Security Official, Joshua Johnson, as he is responsible for information security policies and procedures. Also present in the meeting is the Facility Risk Manager, Angela McDonald. This meeting revealed the following: Audit logs, access reports, and security incident tracking reports are available but not reviewed. There are no policies to address employee access to ePHI. You have no idea which employees have access to protected health information. Of those employees who do have access, you have no way to track or monitor if their access is appropriate. There have been reports of former employees still having access to the hospital’s EHR. There are no policies and procedures for granting access to ePHI through workstations. Employees are not required to change their network passwords. Many employees have had the same password for ten years. Due to short-staffing in the IT Department, security incidents occur, but are not documented. There is no disaster recovery plan. Periodic performance of technical and nontechnical evaluations in response to environmental or operational changes affecting ePHI security is conducted by the ITS Department. The facility does not have any contracts with its business associates. The facility security plan does not address theft. The facility has a robust policy addressing workstation security and use. The policies address workstation functions, how functions are performed at workstations, and the physical attributes and safeguards of the workstation surroundings. Hospital employees have full access to the IT Department. Due to a staffing shortage in the IT Department, employees borrow and take hardware and software without logging their names, dates or equipment taken. Employees can send ePHI without encryption. The facility has a robust procedure for audit controls. Hardware, software, and procedures record and examine activity in the information systems that contain ePHI. The facility has a robust policy and procedure on integrity of ePHI which protect ePHI from improper alteration or destruction and a corroborating electronic mechanism. The facility cannot properly verify that a person seeking ePHI access is the person they claim to be. Documentation regarding policies and procedures are destroyed after one year. Security policies and procedures have not been reviewed and updated in ten years. San Jacinto Hospital HIPAA Security Risk Assessment Tool Standard Met (Y or N) Category Rationale Assigned Security Responsibility Y Administrative Safeguards Hospital has a security official — Joshua Johnson Administrative Safeguards Administrative Safeguards Administrative Safeguards Administrative Safeguards Administrative Safeguards Administrative Safeguards Administrative Safeguards Administrative Safeguards Physical Safeguards Physical Safeguards Physical Safeguards Physical Safeguards Technical Safeguards Technical Safeguards Technical Safeguards Technical Safeguards Technical Safeguards Organizational Requirements Policies, Procedures, and Documentation Critical Thinking Questions Type your answers in a colored font so that they “stand out” from the question. Each answer must contain at least 100 words. Discuss the potential consequences of a HIPAA Privacy or Security violation. 2. Explain the difference between the HIPAA Privacy Rule and the HIPAA Security Rule. 3.Discuss the importance of risk management as it relates to privacy and security of health information. Explain the roles of a privacy official, security official and risk manager. 4. What are the potential risks associated with not conducting regular security risk assessments? 5. Analyze the results of the HIPAA Security Risk Assessment: Rate the organization’s HIPAA Security risk as high, medium, or low (choose one). Justify your response. What inferences can you make about the health of San Jacinto Hospital’s HIPAA security program? 6.Develop at least five (5) recommendations to mitigate the facility’s risk

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