HIPAA Audit Checklist – How to be better Prepared?

Ryan Stephens
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Since the introduction of the Health Information Technology for Economic and Clinical Act (HITECH), it has become more important for healthcare providers and other covered entities to develop a HIPAA audit checklist for better compliance. The purpose of a HIPAA audit checklist is to outline all the elements of HIPAA’s requirements and compare this to the policies, procedures, and measures that have been implemented as a part of the organization’s compliance processes to ensure that there is nothing lacking.

The modifications to HIPAA mandated by the HITECH Act were introduced, in part, because many healthcare organizations lacked the commitment to comply with HIPAA. As a result, the number of breach occurrences involving electronic Protected Health Information (ePHI) has increased. The Office of Civil Rights (OCR) discovered that many covered entities and other healthcare organizations that have been audited did not meet the necessary requirements in the areas of security, privacy, and breach notification. This was due to the fact that these organizations were unaware of the necessary requirements – a problem that a HIPAA audit checklist helps to address. Nevertheless, all covered entities and business associates need to be aware of the audit protocols to avoid hefty fines and penalties.

How to be better prepared for an audit?

A HIPAA audit checklist helps to ensure that everything is in order, documents supporting compliance efforts are readily available, and covered entities and business associates are able to prove that they have given sufficient efforts to comply with HIPAA’s rules and regulations. Here is how organizations can be better prepared in the event of a compliance audit or even a breach investigation:

Organizing documents

In an interview, Doreen Espinoza, Business Development and Privacy Officer of Utah Health Information Network (UHIN), said that the OCR requested and collected a total of 127 documents during an audit. A few of these documents include work desk procedures, training logs, password policies, contracts, incident management, risk analysis, policies and procedures for security and privacy, employee access to PHI, a blueprint of the facility, and many more. According to her, OCR collected all their policies and procedures, lists, diagrams, workflows, and organization charts. The number of documents needing to be maintained can vary for each organization, nevertheless, organizing all the documents is crucial.

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Annual Risk Analysis

Conducting an annual HIPAA risk analysis helps organizations reveal the risks or flaws within their organization. As per the HIPAA Security Rule, organizations are required to conduct a thorough risk analysis to assess potential risks and vulnerabilities of their ePHI. By properly documenting security incidents and potential risks, organizations will be able to be better prepared for an audit.

Performing mini internal audits

Performing internal audits regularly helps organizations to assess if everything is in order and check if the required safeguards and policies implemented are effective or not. Short internal audits can even include walking through the facility to check if the cabinets are locked or if there is a change in HIPAA policy or training requirements. These steps may look very trivial but even the smallest actions can help prevent potential HIPAA violations.

Instill a culture of HIPAA practice within the organization

The culture within an organization is arguably the most important aspect of passing a HIPAA audit. Even if an organization maintains proper documentation, implements required safeguards and policies, if the employees do not believe in the importance of the law, then a potential breach of PHI or a HIPAA violation is more likely to occur. All staff members need to understand the benefits of complying with HIPAA and be committed to the privacy and security practice. A HIPAA audit checklist can properly help an organization if everyone is committed and works as a group. Providing training regularly is a good way to promote HIPAA awareness.

Simplify your compliance and maintain HIPAA Audit Checklist with HIPAAReady

We believe that HIPAA compliance should not be a burden for organizations. With that in mind, HIPAA Ready provides HIPAA compliance solutions for organizations to simplify their compliance efforts. HIPAA Ready is a cloud-based HIPAA compliance software that enables organizations to perform internal audits regularly, assess risks and vulnerabilities within the organization, and keep all documents organized. With an effective training management system through this software, HIPAA Ready allows organizations to easily instill a culture of HIPAA practice for their employees. Leave a comment for inquiries and we will reach out to you within 24 hours!

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