HIPAA Compliance Checklist – Audit Requirements Explained
HIPAA Compliance Checklist – Audit Requirements Explained. In this post, we will introduce HIPAA and explain about HIPAA compliance checklist to understand how to be HIPAA compliant.
The global smart healthcare market size can reach USD 178.5 billion in 2022. You can access great business opportunities in the healthcare sector.
But you should comply with the necessary legalities in the industry. To avoid legal troubles, you must become HIPAA compliant running a healthcare business. But how to do that? What is HIPAA compliance?
Well, understanding HIPAA and following the steps to become HIPAA compliant is a lengthy processes and time consuming.
There are countless instances where healthcare businesses ignored the HIPAA regulations. Then, the governing authorities imposed penalties on them. Remember, you can prevent the mistakes and understand if your organization is subject to HIPAA compliance.
Additionally, we have compiled everything you must know about HIPAA compliance. So, without further ado, let’s start with HIPAA Compliance Checklist – Audit Requirements Explained.
What is HIPAA Compliance?
The Health Insurance Portability and Accountability Act is a collection of aligned regulations created to protect patients’ electronic health records. Accordingly, implementing the HIPAA compliance process involves securing and maintaining sensitive and private patient health data.
Additionally, the data is also known as protected health information (PHI). Therefore, the organizations dealing with PHI must be HIPAA compliant. Also, to achieve HIPAA compliance, you must implement safeguards. These include: risk assessments, reporting, HIPAA training, and so on to protect PHI.
Broadly, only two types of organizations must comply with HIPAA:
- Business Associates.
- Covered Entities.
Look at the checklist to further understand how to be HIPAA compliant.
HIPAA Compliance Checklist
Basically, to comply with HIPAA means you cover different business aspects. To simplify the process, here is a short HIPAA requirements checklist.
1. Dedicate responsible personnel
Firstly, HIPAA compliance is easy to manage when a responsible department or officer handles the process. An excellent practice is dedicating a HIPAA compliance officer to managing compliance related fields. Also, it enables your business with a transparent accountability chain.
2. Develop a HIPAA compliance plan
Secondly, HIPAA has multiple rules your organization must follow to stay compliant. The rules include adherence to different internal procedures and requirements for staff training.
Importantly, your long term organization strategy should include HIPAA relevant fields.
3. Implement policies and procedures
Thirdly, you must ensure that appropriate policies and procedures comply with the HIPAA security, privacy, and breach notification rules. As a matter of fact, You need to create and implement the following:
- Privacy policies and procedures: Keep track of data usage, regular and non regular disclosures, limit requests for sensitive data, and other similar issues.
- Policy for business associates: Modify the existing contracts and agreements signed with your business associates to comply with HIPAA regulations. Furthermore, attaining sufficient assurances in the contracts and document sanctions in case of compliance violations is more important.
- Procedures for PHI access request: Ensure you collect written permissions from patients before sharing or utilizing their PHI for healthcare related operations, including treatment, payment, etc.
4. Implement data safeguards
As noted, implementation of high level data safeguards is critical due to the growing number of cyber attacks globally.
Certainly, cyberattacks can cost companies $10.5 billion worldwide by 2025. To protect your business from cyberattacks, it’s important to incorporate safeguards to become HIPAA certified and protect ePHI.
Consequently, as per the HIPAA regulations, you must implement three specific data safeguards for adhering to HIPAA compliance regulations.
Technical safeguards
At first, technical safeguards in the HIPAA guidelines and Security Rule include:
- Access control: You must implement access control to control access to electronic PHI. Using access control, covered entities must ensure that only authorized personnel can access confidential ePHI.
- Integrity control: Another, step to implement are the set of procedures to verify no change or deletion of ePHI.
- Transmission security: Ensure you take necessary action to protect ePHI whenever they’re either in transit or received.
In a nutshell, technical safeguards require every healthcare business to put appropriate policies & procedures in the right place. Equally, it helps keep ePHI secure whether it’s transmitted, stored, or used.
Physical safeguards
Additionally, you must incorporate physical safeguards to keep ePHI safe, along with technical safeguards. The physical safeguards involve facilities where the PHI is kept and the smart devices required for accessing them.
Follow the below ways to implement physical safeguards:
- Document shredding: Shred and destroy documents containing private and sensitive patient data.
- Workspace security: At the same time, limit workspace and ePHI access only to specific people. You can also implement different policies to regulate when and how workspaces are accessible.
- Mobile device controls: If you enable ePHI access via mobile devices, you must establish precise policies to control how to remove ePHI.
Overall, only authorized personnel should access your facility. Don’t allow anyone without authorization to enter your facility and access workspaces that store ePHI.
Administrative safeguards
The third type of safeguard is an administrative safeguard. At this point, to implement, it requires five parameters:
- Security management process: You must incorporate a security management process to identify all potential security risks to ePHI automatically. Especially, it also analyses the risks and curbs it to a minimum level.
- Information access management system: The HIPAA Privacy Rule limits access and use of ePHI. Therefore, you must employ appropriate procedures to restrict ePHI access based on the individual user’s role.
- Employee’s security awareness and training: Educate your staff members on ePHI and train them to spot and report security breaches. At the same time, also teach them the best cyber security practices to better compliance.
- Evaluation system: Every covered entity or business associate must regularly assess its security policies and procedures.
- Contingency plan: Importantly, craft a contingency plan to safeguard ePHI in emergency times while protecting the confidentiality and integrity of ePHI.
Overall, the administrative safeguard is also critical to implement like the other two safeguards to become HIPAA compliant. Therefore, you must comply with all five specific points explained above.
5. Employee training and communication
After placing safeguards correctly, you should provide extensive training to each employee. Focus on educating them on HIPAA compliance’s significance.
You can begin training by sharing privacy and security related procedures and policies with your employees.
It should be compulsory for employees to read and sign the HIPAA procedures and policies you’ve established.
Additionally, you must ensure every employee undergoes a simple HIPAA compliance course. In fact, you should document HIPAA compliance teaching sessions and employees’ signed agreements of HIPAA procedures and policies.
Avoid unfortunate circumstances in the event of HIPAA compliance infringement by staff members. Develop rigid sanctions and disciplinary regulations.
6. Maintain technologies used for PHI handling
Under HIPAA, you must ensure PHI safety during transmission, use, and rest. Evidently, you must add cybersecurity technologies to your setup and strengthen your security methods.
Outdated systems open the door to hackers. Please plan for periodic security update pushes.
7. Evaluate the current risk level
By all means, HIPAA compliant organizations must regularly perform security audits. Being that way, it makes risk analysis an ongoing matter.
Your audits should cover all administrative and technical policies. The only effective way to stay compliant is by performing periodic checks.
8. Plan for emergencies
Develop an action plan for tackling a cyber attack. As the Breach Notification Rule states, all HIPAA compliant businesses must have processes for unexpected data breach handling notification rules. Cover areas such as notifying customers and other entities.
Establishing appropriate procedures and systems for security breach notification can help minimize data breach damage.
You must keep track of investigations that risk compromising the security of ePHI. Further, create high level standards and strict instructions. Then use mitigation and disciplinary policies the event of a security breach.
Even more, create a protocol for your staff members to notify about every breach. Develop a system to inform the Office for Civil Rights and patients. That is, if the security breach affects 500+ people.
9. Investigate found violations
An investigation into reports about a found HIPAA violation is a must. Indeed, you must provide guidelines and a timeframes for resolving the issues.
The investigation step will follow after all your audits. Resolve the discovered violation before it can be fully HIPAA compliant.
10. Document your findings
Log and record everything related to HIPAA and its actions. Even so, its scope should include all the details from the first steps taken to audit evaluations. Follow an excellent practice by keeping it in one corpus to make HIPAA compliance policies transparent.
11. Find the right partners
If there are lacking resources to manage everything in house; associate it with security vendors that specialize in compliance.
Professional security companies can provide software to match your setup and comply with different HIPAA requirements. However, ensure to choose a trustworthy company to avoid accidentally leaking your data.
Cross check different details and word of mouth of the company to be thorough to the end.
12. Get familiar with the 4 HIPAA rules
Even though, HIPAA establishes 4 rules for safeguarding the security and privacy of a patient’s medical information. Each provides a specific framework for a field detailing how to proceed to HIPAA compliance. You must understand the rules and abide by them to be HIPAA compliant.
Following the above listed compliance checklist for HIPAA can help you avoid legal troubles and keep your patient’s data safe.
Up next with HIPAA Compliance Checklist – Audit Requirements Explained, we will talk about Compliance Audits.
HIPAA Audit Requirements
Being in the health care business, every year to have to conduct six HIPAA audits. The audits access your current HIPAA security, privacy, and notification breach practices against HIPAA standards.
The necessary HIPAA audits include the following:
- Privacy Standards.
- Asset and Device.
- HITECH Subtitle D.
- Security Rule Standards.
- Physical Site.
- Security IT Risk Assessment.
HIPAA Audit
Each HIPAA audit has requirements specific to HIPAA regulations. Have a look.
1. Privacy Standards
The audit requires you to implement procedures and policies to protect health information and train the workforce on these policies.
2. Asset and Device
It requires you to implement procedures and policies related to the security protection of electronic media and update security measures.
3. HITECH Subtitle D
This HIPAA audit requires you to implement procedures and policies related to breach notification and requires dedicated workforce training.
4. Security Rule Standards
This audit requires you to implement policies and procedures complying with the Security Rule. It also requires you to review an environmental or operational change within the organization each year. Last, workforce members should receive security awareness training.
5. Security IT Risk Assessment
The HIPAA audit requires a security risk analysis which you must conduct yearly.
6. Physical Site
Lastly, it requires you to implement policies and procedures. Hence, to limit physical access to electronic devices and modify required security measures. Even if you are working from a home office, you require a physical site audit. Why?
Because your home office contains protected health information, you must protect the information from unauthorized disclosure or access.
HIPAA Compliance Best Practices
Whilst implementing the HIPAA act in your business, do not forget if you do not stay cautious, you can cause HIPAA violations. That way, you prevent most HIPAA violations. So, it is vital to implement HIPAA regulations into your procedures and practice policies.
Here are the best HIPAA practices for avoiding HIPAA violations and being a HIPAA complaint:
- Implement safeguards like password protected encryption and authorization to access patient specific information on all laptops, computers, and devices.
2. Always dispose of information that contains PHI by shredding paper files.
3. Ensure employee should know, that using social media to share patient information violates HIPAA law.
4. If you are accessing patient information at home, ensure password protection for all home laptops and computers.
5. Back up disks that contain PHI and store patients’ information in a HIPAA compliant cloud server.
6. Compliance training can help you avoid a violation. For instance, provide up to date training for handling PHI for employees. Log out of the computers containing patient information when not in use. Also, avoid sharing passwords between employees.
7. Ensure computers have updated antivirus software. It will help keep information protected against malicious software.
8. You should limit emailing PHI if you can send the information another way. When faxing PHI, use a cover sheet.
Following these basic HIPAA practices help you prevent violations and legal troubles.
Thank you reading HIPAA Compliance Checklist – Audit Requirements Explained. We shall conclude.
HIPAA Compliance Checklist - Audit Requirements Explained Conclusion
To summarize, achieving HIPAA Compliance is a time consuming and task. But failing to comply with HIPAA regulations can cause severe penalties. These are criminal charges, fines, and civil action lawsuits.
Nevertheless, HIPAA fines start from $100 to $50,000 (per violation), and the maximum penalty of $1.5 million per year.
Understand different compliance requirements and implement the necessary changes. Consult professionals to make required changes in your existing patient database management and strengthen your security.
