First Healthcare Compliance CONNECT- May 2017

®
CONNECT
An Exclusive Monthly Publication for Clients
Partner Spotlight:
4Med Approved
May 2017
How-To Compliance:
Radiation Safety
Meet Our
Staff: Kelly
CAHPS for
MIPS Survey
Marijuana Laws
Impact Your
Drug Test Policies

Important Compliance Dates
January
1
January
1
January
1
Ongoing from January 1 is the start of MACRA collecting performance
data with last possible day to begin October 2.
2017 EHR Stage 2 Medicaid reporting period is a minimum of any
continuous 90 days between January 1- December 31, 2017.
2017 EHR Stage 3 Medicaid for all new and returning participants,
the EHR reporting period is a minimum of any continuous 90 days
between January 1- December 31, 2017.
February June
21
Effective June 21, 2017, Advanced Beneficiary Notice (ABN) Form
Update -Must use most recent version of CMS R-131.
July
1
Practitioners in 9 states are required to report on claims data on
post-operative visits furnished during the global period of specified
procedures using CPT code 99024, beginning July 1, 2017.
In This Issue:
Important Compliance Dates
Meet Our Staff
Marijuana Laws Impact Your Organization’s Drug Testing Policies
How-To Compliance Series: Radiation Safety
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First Healthcare Compliance, LLC © 2017

Meet Our Staff
Kelly Anderson
National Inside Sales Manager
What aspect of your role do you enjoy the most?
I really enjoy presenting a solution to clients that truly helps solve a problem. When
you can help someone in his or her day to day job and know that you have a part in
making their situation better, relieving them of some stress, that’s a good day!
Before working at First Healthcare Compliance, what was the most unusual or interesting job you’ve ever had?
My very first “real” job, at 16, was to be the “salad” girl at the local steakhouse. I kept the salad bar bins full. One very busy
night, I had to get the 5 gallon tub of blue cheese dressing off the top shelf of the walk-in fridge and dumped the whole thing
all over me, head to toe! Not a good look...
Would you rather have telepathy or telekinesis?
I’m not sure I believe in either, and I’m not sure I WANT to read other’s minds! But if I had to choose, perhaps moving things
around at will could be fun!
CAHPS for MIPS Survey
Partner Spotlight: 4Med Approved
System FAQs
Webinar Q&A: OSHA Bloodborne Pathogen and
Hazard Communication Training
Upcoming Webinar Calendar
Contact Toll Free: 888-54-FIRST 3

By Sheba Vine, JD, CPCO
The growing trend in marijuana laws have presented a unique challenge
for employers— the conflict between federal and state laws
leave most employers in a daze. Given that some states place restrictions
on marijuana drug testing, employers need a clear understanding
to avoid the legal ramifications that can be caused by outdated
drug testing policies.
Marijuana use is illegal under the federal U.S. Controlled Substances
Act of 1970 (CSA), which classifies marijuana as a Schedule I prohibited
substance. As a Schedule I substance, marijuana is considered
to be a substance that: 1) possess a high potential for abuse; 2) has
no currently accepted medical use in the U.S.; and 3) lacks accepted
safety for use under medical supervision.” Meanwhile, in direct contradiction
to the federal law, a majority of states and the District of
Columbia have legalized medical and/or recreational use of marijuana.
Of these states, Alaska, Colorado, Oregon, Washington, California,
Maine, Massachusetts, Nevada and the District of Columbia have legalized
marijuana for recreational use. While many states do not require
employers to accommodate marijuana users, there are a handful
of states that do provide employee protections. These states pose
a challenge for employers and their workplace policies. Employers
operating in these states, including Arkansas, Arizona, Connecticut,
Delaware, Illinois, Maine, Minnesota, Nevada, New York, Pennsylvania
and Rhode Island, must be particularly vigilant to ensure internal
employment policies comport with the law.
As it relates to drug testing, a few states that legalize marijuana place
restrictions on employer drug testing. States such as Arizona, Delaware
and Minnesota prohibit employers from taking negative adverse
4
action against an individual for off-duty marijuana use (for instance
discipline or termination). If an employer wants to take adverse employment
action, it must be able to show that the individual was impaired
by marijuana during work hours. So how is this accomplished?
Employers cannot simply rely on a failed drug test as evidence that an
employee was under the influence of marijuana. Common methods of
drug testing, such as a urinalysis, only indicate recent marijuana use
but cannot differentiate between off-duty use versus an impairment
at the time of testing. This is because these methods test for the presence
of tetrahydrocannabinol (THC) metabolites. But THC remains in
a person’s system for days and even weeks after marijuana consumption.
This means that a drug test is only a starting point- employers
must take additional due diligence steps, such as documenting
evidence of actual on-the-job impairment and determining whether
the individual is a registered marijuana cardholder. Depending on the
state, an exception may exist for safety-sensitive positions (such as
operating machinery or motor vehicles) but for the most part healthcare
positions would not fall into this exception.
In conclusion, marijuana laws vary widely from state to state. Employers
must regularly review this developing area and revise their drug
testing policies to comport with their respective state law(s). Understanding
an employer’s legal rights and responsibilities is paramount
to mitigating risk when dealing with these workplace issues, along
with up to date policies and careful documentation.
This article was originally published in the May/June 2017 PAHCOM
Journal.
First Healthcare Compliance, LLC © 2017

How-To Compliance Series:
Radiation
Safety
First Healthcare Compliance is offering a live online How-To
Compliance Course on Radiation Safety. Participants who successfully
complete the online course will receive a Certificate of Completion in
Radiation Safety.
Course attendees will learn how to:
• Understand the Use of Ionizing Radiation in Healthcare
• Detect Radiation and Exposure Levels
• Limit Radiation Exposure
• Apply Radiation Safety Tips
Course Schedule:
The online course will be taught on June 29th 12pm-1pm EDT
Who Should Attend?
This course is designed for radiology technologists, office managers, and compliance and
healthcare professionals.
Course Instructor:
Jill Brooks, MD CHCO
Senior Director of Education
Register Now!
Contact Toll Free: 888-54-FIRST 5

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Join us on Social Media!
Contact Toll Free: 888-54-FIRST 7

Partner Spotlight
An Interview with Brian Johnson, Senior Director of Online
Education at 4Med Approved.
Who is 4Med Approved?
4Med Approved is a leading content developer and educational
resource on topics for health industry professionals. It was founded
in early 2010 to address the increasing need in the medical community
for clear, unbiased resources and online learning on topics
relating to health information technology, compliance, government
incentives, patient outcomes and more.
We provide unique online e-learning, certification and career gap
training programs fully accredited by ACCME and ANCC for medical
professionals, including providers, consultants, practice managers
and their staff.
Our training is developed by leading Subject Matter Experts (SME’s)
in the healthcare industry and updated regularly with the most current
regulatory and compliance information.
How do your training courses work?
All of our training is presented entirely online through self-paced
or instructor-led programs and is fully accredited for students,
nurses, coders, physicians, H&S and others. Courses are available
in modular learning blocks or as pre-bundled course titles. Online
training allows for flexible scheduling, fast credentialing, and targeted
learning. Your CEU/CME is included, and you won’t find a
more convenient commute!
Certificates are a moderate length course option, most taking 4-9
Hours at a self paced rate. Proficiency Certificate Courses are
perfect to brush up on the basics or as an introduction to a new
area of learning. They typically take 1-4 Hours. We add new titles
monthly, so there is always new training available!
4Med training uses our unique 10/10/10 online training method.
Students begin by covering a 10 minute reading module, followed
by 10 minutes of audio narration and video review of the material.
Finally, we assess and retain the knowledge with a 10 question
quiz and interactive lessons. Each course includes 3-25 modules.
This training method applies to both our Self-Paced training and
our Instructor-Led LIVE webinar workshops which are offered on
our most popular titles once or twice a month. We are also more
than happy to bundle various training modules into one customized
course for your organization!
What kind of training do you offer?
Our training catalog includes fully accredited training and professional
certificates in focused industry categories. We cover
everything you need to stay current with government incentive
programs, health IT, compliance, patient outcomes, and more.
We offer three different levels of learning, based on what each
student needs. Professional Certification courses are the most in
depth, requiring approximately 9-15 Hours to complete. Specialty
Listen to the First Healthcare Compliance podcast!
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First Healthcare Compliance, LLC © 2017

We want to hear from you!
Send us your thoughts and suggestions
to make the First Healthcare Compliance
solution even better.
clientservices@1sthcc.com
Are you tired of rude/unprofessional drivers coming into your office to
pick up your medical waste?
Do you have difficulty getting in touch with people who can answer
your questions or resolve invoice problems?
Feel like you only have a few options for medical waste disposal?
Call Matt at Choice MedWaste to see why people are switching!
Flexible contract terms that make our team earn your business every
month.
Unlimited boxes and pick-ups per year with zero additional fees! Yes
we said zero – forget about all those fuel, energy, and environmental
fees!
Professional, customer focused employees who will exceed your
expectations. We promise that!
Contact Toll Free: 888-54-FIRST 9

System FAQs
Do I need to enter into a BAA with my janitorial service?
A business associate agreement (BAA) is not required with persons or organizations whose functions,
activities, or services do not involve the use or disclosure of protected health information, and
where any access to protected health information by such persons would be incidental, if at all.
Generally, janitorial services that clean the offices or facilities of a covered entity are not business
associates because the work they perform for covered entities does not involve the use or disclosure
of protected health information, and any disclosure of protected health information to janitorial personnel
that occurs in the performance of their duties (such as may occur while emptying trash cans)
is limited in nature, occurs as a by-product of their janitorial duties, and could not be reasonably
prevented. Such disclosures are incidental and permitted by the HIPAA Privacy Rule.
So while a BAA is not required under HIPAA, it is still good practice to have the janitorial service
enter into an agreement to keep any incidental disclosures of PHI confidential. We provide a sample
confidentiality agreement for this purpose in the Dashboard Zone.
Do we need to have an OSHA compliance plan if we are in an office that only conducts administrative/clerical
work?
Remember that OSHA applies to most private sector employees. Many of our questions apply specifically
to medical/clinical environments. However, you can always answer those questions N/A and
make sure that you generally comply with OSHA.
What is a hybrid entity, as mentioned in the sample security policies?
A hybrid entity is an entity that has a mix of both healthcare and other business services.
Examples of hybrid entities include:
• A large corporation that has a self-insured health plan for its employees.
• Grocery store that has a pharmacy.
• A correctional facility with a health care clinic that transmits one or more HIPAA‐covered transactions
electronically.
• A data processing center that conducts health care clearinghouse activities as well as non‐health
care data entry.
• A university, which has a medical center.
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First Healthcare Compliance, LLC © 2017

New White Paper!
Are you prepared to deal with changing marijuana laws?
Providers must be vigilant about this rapidly developing area in order to navigate
complex patient care and employment issues carefully.
Learn more about how marijuana
laws are changing in relation to:
• Patient Care
• Employment and Drug Testing Policies
• Disability Accomodation Policies
Download your copy today!
Contact Toll Free: 888-54-FIRST 11

First Healthcare Compliance hosted two informative webinars on
OSHA’s Bloodborne Pathogen and Hazard Communication Standards
with Kelly Ogle, BS, MS, CMPM, CHOP® of DoctorsManagement,
LLC. (Bloodborne Pathogen Training Webinar and Hazard
Communication Training Webinar).
For employers and employees, Kelly addresses some commonly
asked questions regarding compliance with these two OSHA Standards:
Q: Who is covered by the Bloodborne Pathogen Standard?
A: All employees with risk for exposure to bloodborne pathogens.
Q: When are you required to get tested after a needle stick
injury?
A: You must be tested immediately after a needle stick injury. Your
blood will be drawn for a blood panel. Your physician will determine
when you should come back for subsequent testing.
Q: Can my blood be drawn at my office?
A: Yes; if there is a licensed healthcare provider available to review
your results. They will determine follow-up and possible treatment.
Q: Does every chemical used in the office need to be on the
chemical list?
A: As far as OSHA is concerned, the only chemicals that are required
to be on the list are those hazardous chemicals used in the
office. If the chemical you are using is used in the same manner
as in the household, such as Windex, it does not need to be on
the “Hazardous Chemical List.” Although I recommend that if there
are any chemicals that could cause harm to employees, whether
hazardous or non-hazardous, it is a good idea to carry the SDS for
those chemicals also.
Q: Do we have to use the pictograms on our own labeling of
containers in the office?
A: It is not required, but OSHA says it wouldn’t be a bad idea to have
them on your chemicals anyway.
Q: Is there a specific kind of eye wash station that we need
to have?
A: No specific eye wash station is recommended. However, bottles
are not sufficient. If you get something in your eye, you are supposed
to flush the eyes for at least 15 minutes. This cannot be done
with the bottles because they only hold a small amount of water.
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First Healthcare Compliance, LLC © 2017

Contact Toll Free: 888-54-FIRST 13

Join Us for These Upcoming Webinars
and Earn Complimentary CEU Credits!
May 24th @ 12pm EDT
Common Life Safety Code Deficiencies
and Strategies for Compliance
Stanley J. Szpytek
Fire and Life Safety, Inc
June 6th @ 12pm EDT
Best Practices for
Employee Handbooks
Allyson DiRocco, Esq.
Morris James, LLP
June 20th @ 12pm EDT
Pregnancy and the Workplace:
Employee Rights and Employer
Obligations
Lauren Russell, Esq.
Young Conway Stargatt & Taylor, LLP
June 21st @ 12pm EDT
Patient Safety Challenges:
Communication and Resolution
Initiatives
David M. Sommers, MD, JD, LLM
Medsome LLC
July 11th @ 12pm EDT
Is This a HIPAA Breach
and If So, What Now?
Jennifer Kirschenbaum, Esq.
Kirschenbaum & Kirschenbaum, P.C.
July 26th @ 12pm EDT
Payment Card Industry (PCI) Basics
Kaden Pope
Security Metrics
August 1st @ 12pm EDT
Risk Management Considerations with
Prescription Drug Abuse
Mike Midgley
Swiss Re Corporate Solutions
September 19th @ 12pm EDT
Emergency Preparedness
Requirements
Stanley J. Szpytek
Fire and Life Safety, Inc
October 3rd @ 12pm EDT
Discounts and Waivers:
When are they permissible?
When are they likely illegal?
Robert Liles, Esq.
Liles Parker
October 11th @ 12pm EDT
False Claims Act Liability And
Whistleblower Laws
Shauna Itri, Esq.
Berger & Montague
July 12th @ 12pm EDT
HIPAA Security- Monitoring Access,
Incident Management and Detection
Ray Ribble
SPHER Inc.
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First Healthcare Compliance, LLC © 2017