Compliance Corner July 2024

2024 HIPAA Final Rule:  New Attestation Requirement

June 25, 2024: The HIPAA Privacy Rule has been amended to provide greater protections for protected health information (PHI) related to reproductive health care. Covered entities and business associates should familiarize themselves with the final rule, which imposes new prohibitions on the use and disclosure of PHI, a new attestation requirement, and revisions to privacy notices. Covered entities and business associates will need to revise their policies and procedures to ensure compliance, and may wish to revisit existing business associate agreements.

The changes initiated by the Final Rule went into effect on June 25, 2024. Entities that must abide by HIPAA (covered entities and business associates) must come into compliance with these new requirements, including the attestation requirement, no later than December 23, 2024. There is one exception: the required updates to covered entities’ notices of privacy practices (NPPs), which are addressed in 45 CFR 164.520, do not have to be implemented until February 16, 2026.

The US Department of Health and Human Services Office for Civil Rights has provided a brief educational summary of the HIPAA Privacy Rule to Support Reproductive Health Care Privacy Final Rule which can be found HERE.

Source: HHS


HHS, FBI Warn Healthcare Sector of Social Engineering Scheme

June 24, 2024: The Federal Bureau of Investigation (FBI) and the Department of Health and Human Services (HHS) released a joint Cybersecurity Advisory (CSA) to disseminate known indicators of compromise and tactics, techniques, and procedures used in a social engineering campaign targeting healthcare, public health entities, and providers.  Threat actors are using phishing schemes to steal login credentials for initial access and the diversion of automated clearinghouse payments to US controlled bank accounts.  Healthcare organizations are attractive targets for threat actors due to their size, technological dependence, access to personal health information, and unique impacts from patient care disruptions.  The FBI and HHS encourage organizations to implement the recommendations in the Mitigations section of their CSA to reduce the likelihood and impact of social engineering incidents.  Read the full Advisory HERE.

Source: Joint Cybersecurity Advisory


$56 Million Awarded to HRSA-Funded Health Centers to Support Improving Quality Health Services in High Need Communities

June 20, 2024: The U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), awarded $56 million to support HRSA-funded health centers’ commitment to high-quality care through new investments in modernized technology. HRSA-funded health centers provide primary care to 30 million people and serve patients regardless of ability to pay. They are also leaders in health care quality, and HRSA is taking the next step in quality improvement by adopting a modernized Uniform Data System (UDS+) for health centers. UDS+ will create automated reporting platforms for quality and performance management, streamlining backend work.

Award recipients will use this supplemental funding for new equipment, meeting interoperability standards, and providing data management training to staff.

Read the full release here.

Source: HRSA


The Joint Commission Changes to CCBHC

The Joint Commission has made several significant changes to its Certified Community Behavioral Health Clinic (CCBHC) standards, which take effect July 1, 2024. These changes align with the updated CCBHC criteria released by the Substance Abuse and Mental Health Services Administration (SAMHSA) in March 2023. Here are the key updates:

  • Stronger emphasis on trauma-informed crisis care.
  • Enhanced focus on addressing substance use disorders.
  • Increased efforts to advance health equity.
  • Greater flexibility in care delivery methods, allowing organizations more adaptable approaches to providing care, treatment, and services.

The revisions affect 31 Joint Commission CCBHC Standards across multiple chapters, including Care, Treatment, and Services (CTS), Human Resources Management (HRM), Information Management (IM), Leadership (LD), Medication Management (MM), Performance Improvement (PI), and Rights and Responsibilities of the Individual (RI).

Some specific changes include:

  • Requirements for collecting, reporting, and tracking encounter, outcome, and quality data for all individuals served by the CCBHC and Designated Collaborating Organizations (DCOs).
  • Updates to the quality improvement plan to address all required elements.
  • Ensuring information about CCBHC services is available online and in paper format in languages commonly spoken and at different literacy levels within the community served.
  • Offering all required services for children, youth, adults, and veterans based on a community needs assessment updated at least every three years.

These revisions aim to improve the quality and accessibility of behavioral health services while providing organizations with more adaptable approaches to care. The Joint Commission has provided two reports detailing the updated requirements: a compare report showing all changes and a clean report with only the revised requirements.

Source: TJC


Medicare Information for Patients in Other Languages

Did you know your patients can get information in many other languages on  Patients can now search for Publications in their language.

Patients can also switch to Spanish using the “Cambiar a español” link at the top right of any webpage.



NACHC Resources on Board Composition and Supporting Boards

NACHC has made available resources on board composition and to support boards that are ready to deepen their commitment to Justice, Equity, Diversity and Inclusion in Governance.

Governance Guide for Health Center Boards (English/Spanish):   The Governance Guide for Health Center Boards addresses major areas of board responsibility and contextualizes them, where appropriate, in the Health Resources and Services Administration (HRSA) Health Center Program Compliance Manual (Compliance Manual) and relevant state and federal laws. The Governance Guide also reflects the latest effective governance practices for nonprofit boards. The Governance Guide for Health Center Boards will also be available in Spanish (forthcoming) and replaces the “Health Center Program Governing Board Workbook.”

Considerations for Health Center Boards:  Considerations for Health Center Boards on Diversity, Equity, Inclusion, and Justice in Governance, is a short introductory module intended as a resource for boards starting to explore or reevaluate diversity, equity, and inclusion in health center governance.

Board Actions Combating Racism:  This video case study highlights the board of Lowell Community Health Center, which passed a Board Resolution Declaring that Racism is a Public Health Crisis. In the video, board members discuss the Resolution and how the board is providing oversight of its implementation. Various discussion questions for boards are included at the end of the video, along with links to resources for additional learning.

Source: NACHC


CMS to Close Program Addressing Medicare Funding Issues from Change Healthcare Cyber-Attack

June 17, 2024: The Centers for Medicare & Medicaid Services (CMS) announced that payments under the Accelerated and Advance Payment (AAP) Program for the Change Healthcare/Optum Payment Disruption (CHOPD) will conclude on July 12, 2024. Launched in early March, the CHOPD payments were designed to ease cash flow disruptions experienced by some Medicare providers and suppliers, such as hospitals, physicians, and pharmacists, due to the unprecedented cyberattack that took health care electronic data interchange Change Healthcare offline in February.  Read the full release HERE.

Source: CMS


New Leadership Team Members at NACHC

New Chief Financial Officer: Sean P. Roddy, CPA, CMA, CGMA, MBA, is joining the senior leadership team of National Association of Community Health Centers (NACHC) as the new Chief Financial Officer (CFO). Sean brings a diverse portfolio of skills and experience from private and nonprofit sectors, as well as academia. In his new role he will provide visionary and strategic stewardship in partnership with the President, Executive Board, and leadership team, supporting NACHC’s longstanding role to strengthen and expand the Community Health Center Movement.

New Chief Health Officer: Luis Padilla, MD, will join the senior leadership team of National Association of Community Health Centers (NACHC) as the Chief Health Officer. Dr. Padilla is a thought leader in the Community Health Center Movement who will help direct NACHC’s efforts to advance health equity, grow the primary care workforce and support the mission of health centers, which provide high-quality, affordable, transdisciplinary primary care to over 31.5 million people nationwide.

Source: NACHC

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