Security & Compliance

  • 7 min read

8-Step HIPAA Compliance Checklist

Sreenidhe S.P

2nd April, 2024

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Adhering to HIPAA compliance is essential for healthcare organizations. It sets crucial standards to protect the privacy, security, and integrity of healthcare data. 

While the compliance process can be challenging, a tailored HIPAA compliance checklist is imperative for navigating these complexities.

Comprehending and meeting HIPAA compliance obligations is vital for organizations handling protected health information (PHI). However, navigating HIPAA guidelines can be intricate due to its varying compliance requirements. 

HIPAA-covered entities, like health plans and healthcare providers, must fulfill all compliance requirements, while business associates and exempted entities adhere to specific aspects.

A HIPAA compliance checklist streamlines adherence and provides a clear approach for organizations to align with the relevant guidelines.

Key Considerations & Applicability For HIPAA Compliance

When it comes to HIPAA compliance, it's essential to understand that not all organizations are bound by every standard within the HIPAA Administrative Simplification provisions. While certain entities, such as health plans, healthcare operations, and healthcare organizations, have comprehensive obligations under HIPAA, others may have more specific requirements. 

Here are some key considerations for organizations that should adhere  to HIPAA compliance:-

• Diverse Applicability: Recognize that not all organizations are universally bound by every aspect of the Administrative Simplification provisions of HIPAA.

• Mandatory Compliance for Certain Entities: While health plans, healthcare clearinghouses, and healthcare providers typically must comply with various HIPAA rules, other organizations may have specific obligations, such as adhering only to the Security Rule and/or Breach Notification Rule.

• Varying Requirements in Larger Organizations: Larger organizations may experience different compliance requirements across various departments. For instance, a healthcare facility with public-facing personnel and a remote IT team may have distinct needs, with public-facing compliance focusing on patients' rights and PHI disclosures, while the IT team benefits more from a HIPAA cybersecurity checklist.

• Focus on Latest Protocols: Emphasize adherence to the most recent protocols published by the OCR, ensuring that the provided checklists align with the latest standards in HIPAA compliance.

• FAQ Section for Clarity: The article concludes with an FAQ section, addressing commonly asked questions about HIPAA compliance and associated checklists. This section aims to provide clarity and guidance on key concerns related to HIPAA regulations.

By understanding the varied applicability of HIPAA compliance and tailoring checklists to specific organizational needs, entities can navigate the regulatory landscape effectively and ensure adherence to the relevant rules and protocols.

Consequences of Failing a HIPAA Audit

The consequences of a failed HIPAA audit are multifaceted. The Office for Civil Rights (OCR), which conducts the audits, collaborates with the non-compliant organization to formulate a corrective action plan designed to guide the organization in achieving compliance with HIPAA regulations.

• Collaborative Corrective Action

Failing a HIPAA audit initiates a collaborative process with the Office for Civil Rights (OCR) to develop a corrective action plan aimed at achieving compliance with HIPAA regulations.

• Comprehensive Data Risk Analysis

As part of the corrective action plan, a thorough data risk analysis is conducted to identify vulnerabilities and assess potential threats to the security of protected health information (PHI).

• Implementation of Data Encryption

Measures such as data encryption may be implemented to enhance the safeguarding of sensitive information and address identified vulnerabilities.

• Policy and Procedure Revision

Organizations may need to create, document, and implement new policies and procedures aligned with HIPAA standards to ensure the confidentiality, integrity, and availability of PHI and prevent future non-compliance.

• Mandatory Workforce Training

Workforce training, overseen by the OCR, may be mandated. It should focus on educating employees about HIPAA regulations, emphasizing the importance of maintaining patient information security and ensuring staff familiarity with established policies.

• Financial Repercussions

Despite completing the corrective action plan, there are financial consequences. Fines are imposed based on the severity of violations and categorized into four tiers according to HIPAA's Omnibus Rule.

• Individual Criminal Charges

Individuals within the organization may face criminal charges for specific HIPAA violations, emphasizing the gravity of compliance and the personal responsibility of safeguarding patient information.

• Escalating Fines Based on Severity

Fines escalate based on the severity of violations, highlighting the urgency for organizations to promptly address and rectify issues to mitigate financial penalties.

The consequences of failing a HIPAA audit underscore the critical importance of proactive adherence to privacy and security measures outlined in the regulations.

The Complete HIPAA Compliance Checklist: 8 Crucial Aspects

This comprehensive checklist will guide you through 8 critical aspects of HIPAA compliance, providing actionable insights and practical strategies to help your organization navigate the complexities of HIPAA regulations effectively. 

1. Thoroughly Understand HIPAA’s Three Rules

Implementing the right HIPAA compliance controls starts with understanding the several HIPAA compliance guidelines covered under the Privacy, Security, and Breach Notification Rule. 

The Privacy Rule and Security Rule explain what organizations must do to protect PHI and electronic PHI (ePHI), including detailing what safeguards to put in place to secure sensitive medical data. 

The Breach Notification Rule details remediation requirements an organization must follow if a breach occurs. Organizations must understand the intention of these requirements and review the required technical specifications to create the correct safeguards, procedures, and policies for their organization.

2. Discover Which Rules Apply to Your Organization

To start, determine if your organization qualifies as a covered entity. Covered entities will be responsible for implementing safeguards dictated by the Privacy Rule to protect all PHI—not just electronic data. Even if your organization is an exempt entity or business associate, you may be subject to some Privacy Rule requirements based on agreements you maintain with covered entities.

3. Determine What Data Requires Extra Protection

Individually identifiable health information must be protected under HIPAA regulations, which don’t include all of an organization’s data. Identify what data your organization collects, uses, or stores both physically on paper and within your IT infrastructure. 

Determine how much of that data qualifies as identifiable health information and review how it is collected, retrieved, and deleted. You’ll also want to note who has access to that data and how it’s accessed.

4. Perform A Risk Analysis

Recognizing the gaps in your existing data security practices can help you see where you need more controls or new procedures to become HIPAA compliant. The OCR’s Security Risk Assessment Tool serves as a great HIPAA Security Rule checklist to see how your current controls align with the requirements detailed in the Security Rule.

Audit your current privacy and security policies and procedures to see how they align with the requirements detailed in the HIPAA guidelines. Your organization must maintain data security for PHI in use, at rest, and during transmission, which often requires updating outdated systems. 

Use your analysis to create your own HIPAA risk assessment checklist and develop a compliance plan to close your security gaps and maintain HIPAA standards.

5. Establish Accountability in Your Compliance Plan

Once you understand what your organization needs to do to achieve compliance, define who is accountable for which elements of your compliance plan to promote streamlined, transparent communication. 

Maintaining HIPAA compliance requires regular monitoring, audits, technology maintenance, and training. Establishing responsible parties for those steps early can help companies maintain HIPAA compliance.

6. Avoid Violations by Addressing Gaps

Once you’ve created a compliance implementation and management plan, focus on introducing the privacy and security controls that will mitigate the most risk. Create a HIPAA compliance audit checklist to consistently review your improvements and detect more gaps to address. 

Consider that internal users are often more likely to be responsible for HIPAA violations than external breaches, so prioritize both technical security safeguards—like encrypting data—with physical and administrative safeguards—like using strong passwords and training users to manage data safely.

7. Maintain Detailed Documentation

As you implement data privacy and security improvements to comply with HIPAA guidelines, track all progress with thorough documentation. That can include maintaining versions of your policies and procedures as they’re edited, tracking who attended compliance training sessions, and recording which entities you share PHI with. 

Some documentation may be required for an OCR audit, like policies and procedures, written and electronic communications, and actions requiring a written or typed record. However, it’s best to record as much of your HIPAA compliance process as possible to recognize and mitigate security gaps quickly.

8. Report Security Incidents Immediately

If your organization experiences a security incident, you are required to submit a breach report form to the Secretary of Health and Human Services within 60 days of discovering the breach. 

Following the Breach Notification Rule, the company must also notify all individuals whose PHI it exposed within the same period. For breaches affecting over 500 people, you must also notify local media. 

Reporting a breach will prompt an investigation by OCR. Conduct your own investigation into HIPAA violations and document what you find. Combined with OCR's investigation, this can help you close security gaps and restore your organization's HIPAA compliance.

From grasping HIPAA's three rules to ensuring accountability in your compliance plan, each aspect is meticulously outlined to equip you with the knowledge and tools needed for HIPAA compliance. Ultimately, this ensures your organization maintains the highest standards of patient privacy and data security.

Consistent Evaluation of HIPAA Compliance Checklists

In conclusion, while HIPAA regulations may not undergo rapid changes, the landscape of threats to health information privacy is dynamic. 

To ensure the ongoing efficacy of safeguards, it is advisable to review HIPAA compliance checklists regularly. Although not mandated by HIPAA, an annual review and more frequent assessments in the face of substantial changes to the rules stand as best practices. 

You can enhance your HIPAA compliance efforts by utilizing access review tools like Zluri. Zluri provides comprehensive visibility into app access and entitlements, facilitating complete access assessments. Additionally, Zluri offers robust revocation workflows for auto-remediation, swiftly eliminating high-risk accounts. This proactive approach aligns seamlessly with HIPAA requirements, enabling continuous monitoring and rapid incident response.

Here are some key features that bolster your compliance efforts:-

• Fully Automated Access Reviews

Zluri offers a fully automated access review process, creating a unified experience for all applications and stakeholders. By streamlining and accelerating the process with flexible workflows and bulk actions, Zluri ensures efficiency and effectiveness in access management.

• Contextualized Reviews with Risk Intelligence

The platform contextualizes access reviews with risk intelligence, providing reviewers with accurate, real-time insights into the most high-risk user accounts that require immediate action. This feature enables proactive identification and mitigation of potential security threats.

• Auto-Remediation of Overprivileged Access

With Zluri, organizations can auto-remediate overprivileged access swiftly and effectively. Through powerful auto-remediation capabilities, Zluri instantly deprovisions or downgrades user access after a review, enhancing security and compliance posture.

• Accelerated Compliance with Audit-Ready Reports

Zluri facilitates compliance efforts by delivering audit-ready reports automatically to the inbox. These reports ensure that organizations are well-prepared for audits, saving time and effort while maintaining compliance with regulatory requirements.

Experience reviews 10X faster, a 70% reduction in effort, and enhanced security.

Book a demo now to streamline compliance efforts and ensure a secure IT environment. 

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About the author

Sreenidhe S.P