Complying With HIPAA and JCAHO Requirements Specific security concerns are controlled access to specialized areas, supply rooms and medical carts, especially to control the access to medications, drugs, syringes, and needles. By Rod Oden While adhering to the usual group of local, state...
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Hospitals aggressively seek JCAHO accreditation to meet Medicare and certification and licensure requirements. Accreditation is a condition of reimbursement. Accreditation also reduces liability insurance and other premiums.
JCAHO surveys hospitals annually. Failure to achieve accreditation often leads to fines or accreditation suspension. JCAHO guidelines are numerous and cover all aspects of proper healthcare, including security.
JCAHO requirements are intended to ensure a safe and secure environment and are independent of other local, state, and federal requirements that also cover safety and security (i.e. Uniform Building Code).
JCAHO does require that all NFPA 101 codes be applied, along with their additional requirements.
JCAHO requirements include, but are not limited to: developing a security and emergency management plan; conducting annual risk assessments that evaluate potential adverse environmental conditions that affect the security of patients, staff, and visitors; and using risk analysis to implement procedures and controls to achieve a reduction to the potential for adverse impact on security.
Additional physical security requirements include identifying patients, staff, and visitors entering the facility; controlling traffic into and out of security sensitive areas, as determined by the organization; and mitigating violence in emergency rooms, departments, or other locations.
JCAHO also requires hospitals to provide for education and training to staff, licensed practitioners, and volunteers, pertaining to their performance and responsibilities within their environment.
Specific security concerns regarding JCAHO are controlled access to specialized areas; supply rooms; and medical carts, especially to control the access to medications, drugs, syringes, and needles.
Areas affected by HIPAA and JCAHO
HIPAA focuses on privacy and confidentiality. Wherever medical records are exposed or stored, HIPAA has a concern. Securing file cabinets, installing locks in cabinets, upgrading door locks are typical examples.
Some non-typical considerations relate to access and surveillance systems.
The list of persons having access and their PIN numbers falls into information that must be protected using HIPAA requirements. When persons no longer need access to areas, they are to be immediately removed from access, so the management of the access system must be regulated using HIPAA requirements.
Where surveillance systems are used, if the video is recorded, the storage and exposure to the video might come under HIPAA requirements.
When the locksmith installs these types of systems, it is better that a customer administrator manage these systems, rather than the locksmith. If the locksmith stores or keeps recorded media, where and how it is stored might become a HIPAA issue.
Areas affected by JCAHO standards can be pharmacies; surgery wards; administrative offices; kitchens and food service areas; places where patient and employee records are stored; places where narcotics and medications are stored; and nursing stations.
Most JCAHO standards are clear and direct. These include:
• Rooms where patient or employee records are stored are to be protected with a storeroom function lock. File cabinets used for the same purpose must be lockable.
• Nursing stations must use separate drawers or cabinets to store medical records, needles and syringes and emergency medications.
• Refrigerators designated for drugs must be locked at all times and under surveillance. No food can be stored in these refrigerators.
• Medical carts must be locked with no one is in attendance.
• All doors are to be self-latching.
• In pediatric wards locks can be raised to prevent children from leaving without notice.
Some requirements concerning “security-sensitive” or controlled areas are challenging to setup as JCAHO has strict requirements relating to controlling “access to” and “egress” from these areas, while prevailing life safety codes demand immediate egress from the same areas. JCAHO does require compliance of NFPA 101 Life Safety Code (LSC).
In areas that must be both JCAHO and LSC compliant, there are several areas within LSC that deal with exceptions to immediate egress in healthcare environments:
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