HIPAA Compliance Audits

Healthcare facilities and treatment centers are responsible for prioritizing HIPAA compliance which aims to safeguard the confidentiality and security of patient health information (PHI). By complying with the rules of HIPAA, the privacy and protection of sensitive data is ensured.

To confirm an organization’s compliance, the Department of Health and Human Services’ Office for Civil rights (OCR) carries out periodic reviews and assessments of their adherence to HIPAA. These audits encourage healthcare organizations to take proactive approaches to security that demonstrate their dedication to patient safety.

What is a HIPAA Compliance Audit?

A HIPAA compliance audit is an examination hosted by the OCR to assess how an organization and its business associates (BA) handle PHI.

During these audits an organization’s policies, procedures, security measures, and practices are examined to ensure strict compliance with HIPAA. If the OCR finds that a healthcare organization is not complying with HIPAA there may be consequences including creating corrective action plans or imposing monetary fines as a penalty, depending on the severity of the violation.

Which Organizations are Audited?

In such a vast industry, conducting routine audits with every single healthcare organization is impractical. So, the OCR must have a method of selecting organizations for an audit based on a variety of factors. Some of those factors include complaints against the organization, a data breach the organization is facing, or random selection by the OCR.

With the rise of cybercriminal activity and the possibility of random selection, all healthcare organizations must take proactive measures to ensure they are HIPAA compliant. These measures will help healthcare teams protect sensitive patient data, by upholding the strict standards of HIPAA.

How to Prepare for a HIPAA Compliance Audit

Preparation is key when it comes to unexpected HIPAA compliance audits, so these are some tips on how to stay prepared:

Know the Five Main Rules of HIPAA

There are five main rules that are outlined by HIPAA and knowing them will give organizations a better understanding of HIPAA regulations as a whole. Those rules are:

The Privacy Rule – explains the limits about how PHI can be used without requiring patient authorization, as well as allows patients to view and receive a copy of their medical records.
The Security Rule – defines all of the safeguards that must be met to securely store, access, and transmit PHI.
The Transaction Rule – addresses standardized formats and codes that must be used when electronically exchanging medical records.
The Identifiers Rule – outlines the specific components that an organization can use to identify an individual in their health records.
The Enforcement Rule – goes over the penalties an organization will face if they violate the rules set by HIPAA.
Assign a HIPAA Compliance Officer

It is crucial that a knowledgeable HIPAA compliance officer is appointed when preparing for a HIPAA compliance audit. This person must have a comprehensive understanding of HIPAA to successfully oversee the organization’s efforts for compliance. Additionally, they should host internal audits where they assess the organization’s adherence to the guidelines, so in the event of an official audit, they are prepared.

Review and Update Current Policies and Procedures

Organizations must be informed about any revisions made to the guidelines of HIPAA. When rules and regulations are updated, there are times when previously established policies no longer comply with HIPAA. This highlights the importance of staying up-to-date on changes within HIPAA and revising internal rules accordingly.

Train Staff on HIPAA

An organization’s compliance with HIPAA goes beyond the implementation of internal policies. To effectively protect PHI, all staff members must be sufficiently trained on these policies, so that they can fully understand and execute them. Without adequate training, patient data may be susceptible to cyber attacks, leaving patients vulnerable. Furthermore, keeping record of training days is crucial documentation that should be shared with the OCR to verify HIPAA compliance efforts.

Maintain Documentation

Maintaining comprehensive documentation is crucial for organizations handling compliance audits. By offering records of training days, audit trails, and agreements with BAs, the OCR will be able to thoroughly review an organization for compliance. Not only will this practice demonstrate the organization’s HIPAA compliance, but their continued dedication to patient safety as well.

HIPAA Compliance Audit Follow-up

In the event of a HIPAA compliance audit, organizations should have a follow-up plan in place to ensure the timely implementation of necessary changes for HIPAA compliance. Following an audit, these are some of the actions an organization should take:

Review the Audit Report

The OCR will provide an audit report outlining any findings or recommendations regarding HIPAA compliance that the organization must take into account. These reports should be reviewed so that there is a clear understanding about what the organization’s next steps should be.

Identify Necessary Policy Changes

After reviewing the audit report an organization must review their policies and incorporate the OCR’s suggestions into the revised policies. This will empower healthcare organizations to enhance their efforts in protecting sensitive patient information and ensure their compliance with HIPAA.

Documentation

It is important that an organization maintains documentation after a HIPAA compliance audit to demonstrate their adherence to HIPAA and dedication to protecting sensitive patient data.

Continuous Improvement

Updating policies right after an official audit is a great practice, but it is not enough. Healthcare organizations must make continuous efforts for strict HIPAA compliance by staying up-to-date on evolving HIPAA regulations, adopting HIPAA compliant messaging applications, and routinely conducting internal audits.

Best Practices for HIPAA Compliance

Along with the technical rules that must be followed when preparing for a HIPAA Compliance audit, teams can utilize these best practices when striving for a successful audit outcome:

Conduct internal audits

Whether or not an organization is selected for an official HIPAA compliance audit it is a good practice for them to conduct audits internally. These in-house examinations encourage teams to pinpoint any internal policies that may not be up to HIPAA’s current standards. This audit should be directed by the HIPAA compliance officer, so that they can oversee the process and make any necessary changes to internal policies.

Access controls

Organizations should employ technology that is equipped with access controls to ensure that only authorized staff members have access to a patient’s sensitive data. Additionally, this technology should be capable of maintaining comprehensive audit trails that successfully document who accessed sensitive data and when.

Remove outdated technology

Some technologies commonly used by healthcare teams, like pagers, can put patient data at risk. These legacy technologies are unencrypted, leaving them vulnerable to attack. By investing in HIPAA compliant text messaging solutions and other modern technology, healthcare teams can secure patient data while simultaneously improving patient care.

Develop an incident response plan

In the event of a data breach, healthcare teams should have a structured incident response plan that can immediately be deployed to mitigate lost data. This proactive practice is essential to safeguarding patient data, as well as verifying HIPAA compliance efforts to the OCR.

How OnPage Enables Successful HIPAA Compliance

OnPage is an innovative tool that equips healthcare teams with a HIPAA compliant messaging solution that empowers healthcare teams to securely collaborate on patient cases, enabling them to improve patient care while remaining HIPAA compliant. Some of the robust features that OnPage has that will ensure your team’s HIPAA compliance are:

HIPAA Compliant Text Messaging

OnPage’s messaging features are secure and encrypted, allowing physicians to securely exchange contextual messages and include attachments without risking lost patient data or HIPAA non-compliance. This feature allows teams to ditch legacy technology that leaves them susceptible to breaches and further improve their HIPAA compliance efforts.

Comprehensive Audit Trails

When delivering messages with sensitive data it is important that a record of who accessed the data and when is kept. OnPage allows teams to track messages with receipts that identify when a message was sent, delivered, and read so that they can keep track of patient data access.

Access Controls

When delivering messages it is important to ensure that only authorized individuals are accessing PHI. With OnPage, users must go through a two-factor authentication to verify that the authorized user is accessing the data. Additionally, OnPage allows administrators to remotely wipe data from specific users, ensuring that individuals who may no longer be authorized users do not have access to sensitive data anymore.