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Once a breach has been definitively established, which task should be prioritized next?
According to the IAPP CIPP/US study guide, the first priority after a breach has been confirmed is to notify the affected individuals, regulators, and other stakeholders as required by law or contract. This is to allow them to take steps to protect themselves from potential harm, such as identity theft, fraud, or reputational damage. Providing timely and accurate notice also helps to mitigate legal liability, preserve customer trust, and comply with applicable laws and regulations. The other tasks are also important, but they are not the immediate priority after a breach has been established.Reference:IAPP CIPP/US study guide, Chapter 6, Section 6.4.2, page 211.
SuperMart is a large Nevada-based business that has recently determined it sells what constitutes ''covered information'' under Nevada's privacy law, Senate Bill 260. Which of the following privacy compliance steps would best help SuperMart comply with the law?
Nevada's privacy law, Senate Bill 260 (SB 260), is an amendment to the existing Nevada Revised Statutes (NRS) Chapter 603A that was enacted in June 2021 and will take effect on October 1, 2021. SB 260 expands the scope and definition of ''covered information'' under NRS 603A to include any information that identifies, relates to, describes, or is capable of being associated with a consumer, such as name, address, email, phone number, social security number, biometric data, geolocation data, and online identifiers. SB 260 also grants Nevada consumers the right to opt out of the sale of their covered information by an operator of a website or online service that collects and maintains such information.
Under SB 260, an operator is defined as a person who owns or operates a website or online service for commercial purposes, collects and maintains covered information from consumers who reside in Nevada and use or visit the website or online service, and purposefully directs its activities toward Nevada. A sale is defined as the exchange of covered information for monetary consideration by the operator to a person for the person to license or sell the covered information to additional persons. However, there are some exceptions to the definition of a sale, such as:
If the consumer has consented to the sale after being provided with clear and conspicuous notice of the sale and the opportunity to opt out.
If the sale is to a person who processes the covered information on behalf of the operator.
If the sale is to a person with whom the consumer has a direct relationship for the purposes of providing a product or service requested by the consumer.
If the sale is to a person for purposes that are consistent with the reasonable expectations of the consumer considering the context in which the consumer provided the covered information to the operator.
If the sale is to a person who is an affiliate of the operator.
If the sale is to a person as an asset that is part of a merger, acquisition, bankruptcy, or other transaction in which the person assumes control of all or part of the operator's assets.
To comply with SB 260, an operator that sells covered information must provide a designated request address through which a consumer may submit a verified request to opt out of the sale. The designated request address may be an email address, a toll-free telephone number, or an Internet website. The operator must respond to the verified request within 60 days, and may extend the response period for an additional 30 days if reasonably necessary. The operator must also provide a notice to the consumer that identifies the categories of covered information that the operator collects and the categories of third parties to whom the operator may disclose the covered information.
Therefore, the best privacy compliance step for SuperMart to comply with SB 260 is to provide a mechanism for consumers to opt out of sales, as this is the core requirement of the law. Option A is the correct answer.
Option B is incorrect, as SB 260 does not grant consumers the right to access or delete their covered information, unlike other state privacy laws such as the California Consumer Privacy Act (CCPA) or the Virginia Consumer Data Protection Act (VCDPA).
Option C is incorrect, as SB 260 does not require operators to provide a notice of financial incentive for any loyalty programs offered to their customers, unlike the CCPA.
Option D is incorrect, as SB 260 does not impose service provider restrictions on the vendors of the operators, unlike the CCPA or the VCDPA.
[IAPP CIPP/US Study Guide], Chapter 10: State Data Security Laws, pp. 229-230.
In a case of civil litigation, what might a defendant who is being sued for distributing an employee's private information face?
SCENARIO
Please use the following to answer the next question;
Miraculous Healthcare is a large medical practice with multiple locations in California and Nevad
a. Miraculous normally treats patients in person, but has recently decided to start offering teleheaith appointments, where patients can have virtual appointments with on-site doctors via a phone app
For this new initiative. Miraculous is considering a product built by MedApps, a company that makes quality teleheaith apps for healthcare practices and licenses them to be used with the practices' branding. MedApps provides technical support for the app. which it hosts in the cloud MedApps also offers an optional benchmarking service for providers who wish to compare their practice to others using the service
Riya is the Privacy Officer at Miraculous, responsible for the practice's compliance with HIPAA and other applicable laws, and she works with the Miraculous procurement team to get vendor agreements in place. She occasionally assists procurement in vetting vendors and inquiring about their own compliance practices. as well as negotiating the terms of vendor agreements Riya is currently reviewing the suitability of the MedApps app from a privacy perspective.
Riya has also been asked by the Miraculous Healthcare business operations team to review the MedApps' optional benchmarking service. Of particular concern is the requirement that Miraculous Healthcare upload information about the appointments to a portal hosted by MedApps
What is the most practical action Riya can take to minimize the privacy risks of using an app for telehealth appointments?
When handling sensitive data, such as protected health information (PHI) in compliance with HIPAA, it is crucial for covered entities, such as Miraculous Healthcare, to ensure that their business associates (e.g., MedApps) appropriately safeguard the data they process. While contracts like Business Associate Agreements (BAAs) establish the obligations of business associates, active oversight by the covered entity is a practical and necessary step to mitigate privacy risks and ensure compliance.
Why Active Oversight is the Best Option:
Active oversight involves regular monitoring, audits, and reviews of MedApps' practices to ensure they comply with the agreed-upon privacy and security obligations.
This approach allows Miraculous Healthcare to confirm that MedApps is implementing appropriate technical and organizational safeguards, such as encryption, secure access controls, and breach notification processes.
It also ensures that MedApps remains compliant with HIPAA requirements over time, even if there are changes to the app, its services, or legal requirements.
Explanation of Options:
A. Prevent MedApps from using copies of the patient data: While restricting MedApps from creating unnecessary data copies could reduce some risks, it is often impractical, especially for troubleshooting, app hosting, and support purposes. HIPAA does not require outright prevention of data copies, as long as PHI is appropriately safeguarded and used solely for permissible purposes.
B. Require MedApps to obtain consent from all patients: Under HIPAA, covered entities (not business associates) are primarily responsible for obtaining patient consent or authorization where required. MedApps, as a business associate, processes PHI on behalf of Miraculous Healthcare and is not in a position to obtain consent directly from patients.
C. Require MedApps to submit a SOC2 report: A SOC 2 (Service Organization Control 2) report can provide valuable assurance regarding MedApps' security, availability, and confidentiality practices. However, this action alone does not mitigate all risks, as SOC 2 reports are point-in-time assessments and may not reflect ongoing compliance or address specific HIPAA requirements.
D. Engage in active oversight of MedApps: This is the most practical and comprehensive approach. Active oversight includes reviewing MedApps' privacy practices, conducting periodic assessments, and monitoring compliance with the Business Associate Agreement (BAA). It ensures that MedApps continues to protect PHI appropriately and addresses any privacy risks proactively.
Additional Context:
In the context of the optional benchmarking service, Riya should ensure:
The uploaded data is de-identified or aggregated to comply with HIPAA's de-identification standard (45 CFR 164.514) if possible.
The use of PHI for benchmarking is explicitly addressed in the BAA or a separate agreement.
Reference from CIPP/US Materials:
HIPAA Privacy Rule (45 CFR 160.103 and 164.504): Describes the responsibilities of covered entities and business associates, including the need for BAAs and safeguards for PHI.
NIST Privacy Framework and NIST SP 800-53: Provides guidance on implementing oversight mechanisms for third-party risk management.
IAPP CIPP/US Certification Textbook: Discusses the importance of vendor management and active oversight in ensuring privacy compliance.
Conclusion:
Requiring MedApps to submit a SOC 2 report or restricting data use might address specific concerns but would not provide the comprehensive, ongoing protection necessary to reduce risks effectively. Engaging in active oversight is the most practical and effective action to minimize privacy risks while maintaining compliance with HIPAA.
A covered entity suffers a ransomware attack that affects the personal health information (PHI) of more than 500 individuals. According to Federal law under HIPAA, which of the following would the covered entity NOT have to report the breach to?
According to the Health Insurance Portability and Accountability Act (HIPAA), a covered entity is a health plan, a health care clearinghouse, or a health care provider that transmits any health information in electronic form in connection with a transaction covered by HIPAA. A covered entity must report a breach of unsecured protected health information (PHI) to the following parties:
The Department of Health and Human Services (HHS), which is the federal agency responsible for enforcing HIPAA and issuing regulations and guidance on privacy and security issues. A covered entity must notify HHS of a breach affecting 500 or more individuals without unreasonable delay and in no case later than 60 days after discovery of the breach. A covered entity must also notify HHS of breaches affecting fewer than 500 individuals within 60 days of the end of the calendar year in which the breaches occurred.
The affected individuals, who are the individuals whose PHI has been, or is reasonably believed to have been, accessed, acquired, used, or disclosed as a result of the breach. A covered entity must notify the affected individuals without unreasonable delay and in no case later than 60 days after discovery of the breach. The notification must be in writing by first-class mail or, if the individual agrees, by electronic mail. The notification must include a brief description of the breach, the types of information involved, the steps the individual should take to protect themselves, the steps the covered entity is taking to investigate and mitigate the breach, and the contact information of the covered entity.
The local media, if the breach affects more than 500 residents of a state or jurisdiction. A covered entity must notify prominent media outlets serving the state or jurisdiction without unreasonable delay and in no case later than 60 days after discovery of the breach. The notification must include the same information as the notification to the affected individuals.
A covered entity does not have to report the breach to medical providers, unless they are also affected individuals or business associates of the covered entity. A business associate is a person or entity that performs certain functions or activities on behalf of, or provides certain services to, a covered entity that involve the use or disclosure of PHI. A covered entity must have a written contract or agreement with its business associates that requires them to protect the privacy and security of PHI and report any breaches to the covered entity.
IAPP CIPP/US Body of Knowledge, Domain II: Limits on Private-sector Collection and Use of Data, Section C: Sector-specific Requirements for Health Information
IAPP CIPP/US Certified Information Privacy Professional Study Guide, Chapter 2: Limits on Private-sector Collection and Use of Data, Section 2.3: Sector-specific Requirements for Health Information
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