Title
School of Nursing: HIPAA Standard
Unit Standard
Introduction
Purpose
To ensure all faculty, staff and students are aware of their responsibilities and accountability for safe-guarding privacy.
Scope of Applicability
All School of Nursing (SON) faculty, staff and students.
Standard
Health Insurance Portability and Accountability Act (HIPAA) Requirement for Faculty
Federal privacy legislation passed in 1996 affects the healthcare and insurance industries by ensuring uninterrupted health insurance for employees as they move to a different job, and protects the privacy and confidentiality of protected health information (PHI) by setting and enforcing standards. In general, the law defines PHI as information created by a healthcare provider, for use in the treatment of an individual or to obtain payment for such treatment, and that is likely to identify that individual.
The UNC Health Care System (HCS) requires that all members of the workforce be trained on policies and procedures related to protecting the privacy and security of PHI. Because many of our faculty supervise students, practice, or conduct clinical research at UNC HCS or at other health care facilities that have similar training requirements, all SON faculty and students are required to complete HIPAA Online Training annually.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Required Tutorial:
- Proceed to the "HIPAA Privacy and Security Rule Training" webpage on the UNC Environment, Health & Safety website.
- Please complete the tutorial and then the post-test found under the OTHER NON-EHS TRAINING section:
- HIPAA Training at UNC-Chapel Hill - Course #9501
- The post-test is automatically graded by the system and the results returned to you via your email address. A score of 70% is required on each test.
- Print and upload your test results to appropriate repository.
For New Faculty
When faculty are initially employed in the SON, the Office of Administrative Services (OAS) will include information about HIPAA training with the pre-employment packet and the HIPAA training instructions to follow.
For Returning Faculty
Faculty will annually receive notice from the University Employee Occupational Health Clinic (UEHOC) to renew their HIPPA training. Upon completion of training and printing the completion certificate, faculty will upload the certificate to UEHOC. The SON Clinical Support Division will notify the appropriate Academic Associate Dean of faculty who fail to meet this annual requirement.
Faculty who are not in compliance with HIPAA training requirements will not be allowed to have patient contact and/or supervise students in the clinical setting until the HIPAA training requirements are met. Additionally, Academic Associate Deans will document noncompliance with the annual faculty evaluation and merit raises may be adversely affected.
This policy applies to all SON faculty regardless of percent work effort with the School.
Health Insurance Portability and Accountability Act (HIPAA) Requirement for Students
Federal privacy legislation passed in 1996 affects the healthcare and insurance industries by ensuring uninterrupted health insurance for employees as they move to a different job, and protects the privacy and confidentiality of protected health information (PHI) by setting and enforcing standards. In general, the law defines PHI as information created by a healthcare provider, for use in the treatment of an individual or to obtain payment for such treatment, and that is likely to identify that individual.
The UNC Health Care System (HCS) requires that all members of the workforce be trained on policies and procedures related to protecting the privacy and security of PHI. Because many of our students are educated or conduct research at UNC HCS or at other health care facilities which have similar training requirements, all SON students are required to complete HIPAA Online Training annually.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Required Tutorial:
- Proceed to the "HIPAA Privacy and Security Rule Training" webpage on the UNC Environment, Health & Safety website.
- Please complete the tutorial and then the post-test found under the OTHER NON-EHS TRAINING section:
- HIPAA Training at UNC-Chapel Hill - Course #9501
- The post-test is automatically graded by the system and the results returned to you via your email address. A score of 70% is required on each test.
- Print and upload your test results to your CastleBranch account.
The SON Clinical Support Division will be responsible for monitoring student compliance with the annual HIPAA requirement. Any student who fails to complete and maintain currency with HIPAA training will not be allowed to participate in clinical activities until the requirement is met, and the student's grade and progression in their program may be jeopardized.
Health Insurance Portability and Accountability Act (HIPAA) Requirement for Staff
Federal privacy legislation passed in 1996 affects the healthcare and insurance industries by ensuring uninterrupted health insurance for employees as they move to a different job, and protects the privacy and confidentiality of protected health information (PHI) by setting and enforcing standards. In general, the law defines PHI as information created by a healthcare provider, for use in the treatment of an individual or to obtain payment for such treatment, that is likely to identify that individual.
The UNC Health Care System requires that all members of the workforce be trained on policies and procedures related to protecting the privacy and security of personal health information. Because most of our staff members deal with faculty or students who potentially deal with PHI, all staff members at the SON are required to complete the appropriate HIPAA Online Training at the time of hire, and depending on position within the School, on an annual basis.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Required Tutorial:
- Proceed to the "HIPAA Privacy and Security Rule Training" webpage on the UNC Environment, Health & Safety website.
- Please complete the tutorial then the post-test found under the OTHER NON-EHS TRAINING section:
- HIPAA Training at UNC-Chapel Hill - Course #9501
- The post-test is automatically graded by the system and the results returned to you via your email address. A score of 70% is required on each test.
- Print and submit your test results to your supervisor for filing in your official file.
For Permanent SON Staff Members
When permanent SON staff members are initially employed in the SON, the Office of Administrative Services (OAS) shall inform the staff member about the required online training.
Option #2 (employee does NOT work in a Clinical Department, and does NOT conduct research that deals with PHI) is applicable to most staff members, and the online assessment test must be successfully completed and passed at a score of 70% or higher. The supervisor will verify with the staff member which option for the online training is most appropriate for the staff member. This training is required once (unless staff member's supervisor requires annual training). New staff members are expected to take the online training within two weeks of receiving a PID.
OAS shall maintain a current and accurate database of staff compliance with the annual HIPAA requirement. OAS will communicate with the staff member's supervisor about noncompliance if the staff member did not respond to a second notice from OAS. Failure to comply with the HIPAA requirement of online training will be reflected on the staff member's WPPR. This policy applies to all permanent SON staff members, regardless of percent work effort with the School.
For Temporary SON Staff Members
Supervisors of temporary SON staff members (including Tar Heel temps) will determine if HIPAA training is needed for the position, and the frequency of the training. The staff member's supervisor will ask the staff member to take the online training and identify which training is needed. Supervisors are responsible for monitoring compliance of temporary staff members. A temporary staff member's employment may be jeopardized for failure to comply with required HIPAA training.
Exceptions
N/A
Definitions
N/A
Related Requirements
N/A
Contact Information
Primary Contact
Dr. Peggy Wilmoth Executive Dean, Associate Dean Academic Affairs
Other Contacts
N/A
Important Dates
- Effective Date and title of Approver: No approval dates listed on the original document.
- Revision and Review Dates, Change notes, title of Reviewer or Approver:
Approved by:
Dr. Peggy Wilmoth
Executive Dean, Associate Dean Academic Affairs