How to Keep Your HIPAA Compliance Program Running Smoothly

When it comes to keeping your HIPAA compliance program running smoothly, there are 7 key rules your company should follow, which were established by the Office of the Inspector General (OIG) for the HHS. We list out the 7 rules below, you can find the full training guide here

  1. Implement written policies, procedures, and standards of conduct. If any personnel in your workforce are uncertain of how to maintain compliance, they should be able to reference documents whenever they need to. 
  2. Your company should designate a compliance officer and a compliance committee. Having multiple levels of accountability will help ensure that all relevant parties are doing their due diligence to maintain compliance. 
  3. Conduct training and education related to maintaining HIPAA compliance and general data security best practices. All sensitive data, not just PHI, should be safe and secure with your organization. 
  4. All personnel should be able to contact the authorized parties to address an issue or question related to HIPAA compliance. For this reason, it’s critical that your organization maintain clear and effective lines of communication. 
  5. Make sure that your company is conducting internal monitoring and auditing of your compliance security program. Cyberthreats become more sophisticated over time so it should be expected that what worked a year ago may not work today. Pay special attention to changes in data security.
  6. All employees should be aware of the consequences of violating HIPAA compliance, so it’s good practice for your organization to enforce your security policy standards via well-publicised disciplinary guidelines. 
  7. In the event of a data breach or a suspected data breach, make sure your company is able to promptly report and respond to the event to mitigate/prevent any further offenses. 

HIPAA Compliance Risk Assessment 

We’re going to walk through how to perform proper HIPAA compliance risk assessments, as determined by the Office of Civil Rights (OCR). 

Determine the Scope of Analysis

When determining the risks to your organization’s PHI security, ask yourself, “Where does our company keep our PHI and ePHI? Are those locations and storage situations secure? Have we audited the security of these storage areas? 

Your company needs to clarify where your sensitive PHI data is and what you’re currently doing to protect it if you’re to understand where the cracks may be in your security. 

Clarify Your Means of Data Collection

How do you store your company’s PHI? On paper? In online documents? Is it easy to find and classify your PHI? The OCR will be thorough if they’re ever to investigate a HIPAA violation, so it’s best to know exactly where any PHI data is and to document how you collect it. 

Stress Test Your Security to Identify Vulnerabilities

It’s one thing to set up security measures to protect your PHI; it’s another thing to try to undermine your security to identify any potential vulnerabilities. Put yourself in a hacker or thief’s position and ask, “How can I break into these systems and steal this data? 

If you come up with a way to bypass your own security, you’ll know exactly what improvements to make. 

Make an Assessment of Current Security Measures

Similar to the last point, you’ll want your organization to conduct a thorough assessment of what security measures are currently in place. Once you know what you have, you’ll be able to identify how your company can improve, update, or swap out old security technologies. 

Determine the Likelihood of a Threat Occurrence

While it’s true that some businesses are more likely to get attacked than others, with the consistent increase in cyber attacks every year, it’s safe to say that your organization is at greater risk now more than ever. 

The likelihood of an attack is yet another reason to make sure that your organization is prepared to protect your sensitive data. 

Identify the Level of Risk

If someone were to try to steal from your organization, how likely is it that they would manage to acquire PHI? The attacker might not be directly looking for PHI, but if they steal a device that contains it or hack into a database that includes it, that would still count as a breach. 

If you have physical servers that contain PHI and they aren’t stored in a locked server room, the risk of theft is considerably higher than if the room were rocked and monitored. 

Document Relevant Information

Document as much as you can, from your process for sorting PHI to the steps you take to recover PHI in the event of a data breach. 

Review and Update Your Company’s Risk Assessment

Your organization’s risk profile should be updated at least every few months. 

Keeping Your Company’s Private Data Secure 

If your company works with personal health information (PHI), it’s important that you see HIPAA compliance as more than just a law you must abide by. 

Your PHI is data that your organization is responsible for, and the protection and security of your data is critical to thriving in the modern digital age. 

If you’re uncertain of your business’s security or compliance, our IT Security and Compliance Auditing services, you’ll be able to get a complete picture of the security of your IT systems, network, and data.