• Blog
  • Services
    • PHIshMD Ongoing Training
    • HIPAA Compliance
    • Discover Vulnerabilities to Patient PHI
  • Store
    • HIPAA Secure Now Service Store
  • Contact Us
    • Sales Inquiry
    • Customer Support
  • Resources
    • Free Healthcare Security Check Up Quiz
    • HIPAA Compliance Requirements | A Guide
    • Webinars & Downloadable Content
    • Use our free Breach Cost Calculator
    • HIPAA Secured Seal
    • In-Email Training & Analysis | Catch Phish

Call us at: 877-275-4545

Client or Partner? Login here
HIPAA Secure Now!HIPAA Secure Now!
  • Blog
  • Services
    • PHIshMD Ongoing Training
    • HIPAA Compliance
    • Discover Vulnerabilities to Patient PHI
  • Store
    • HIPAA Secure Now Service Store
  • Contact Us
    • Sales Inquiry
    • Customer Support
  • Resources
    • Free Healthcare Security Check Up Quiz
    • HIPAA Compliance Requirements | A Guide
    • Webinars & Downloadable Content
    • Use our free Breach Cost Calculator
    • HIPAA Secured Seal
    • In-Email Training & Analysis | Catch Phish

Details of the HIPAA audits

August 4, 2011 Posted by Art Gross HIPAA No Comments

Health Info Security has published the transcript from an interview with Susan McAndrew of the Department of Health and Human Services’ Office for Civil Rights. The article is very good and should be read in its entirety. Below are some of the key points.

When asked if business associates as well as covered entities will be part of the 150 audits, McAndrew responded:

Eventually. I’m not sure whether business associates will be part of the initial selection process because they are a little more difficult to obtain information about. We don’t have a list or a registry yet of who is a business associate. We’re still strategizing as to how to collect information about business associates to make a meaningful selection, but we certainly are looking to KPMG to have protocols developed to give us the capability of auditing business associates.

It’s unclear at this point whether or not we will be able to conduct and test the business associate protocols. We are hopeful of being able to do so. The primary focus is going to be on the protocols for the covered entities and proving the audit results with regard to covered

If should be interesting to see how they collect the list of business associates. Will they require each covered entity to identify their own business associates?

When asked if the audits will be looking for general compliance or more specific issues of compliance McAndrew replied:

However, at least initially, because we’re very interested in assuring that the protocols are complete and provide comprehensive feedback to us on the degree of compliance, we will be focusing primarily on more comprehensive aspects of compliance

That can be read into as they will be looking to see how closely an organization is compliant with the HIPAA regulations. High level may include policies and procedure, when the last risk assessment was conducted, employee training, incident response procedures, etc.

When asked about onsite audits and if results will be publicly published, she responded:

The model that we’re testing is your typical onsite audit. … There will definitely be advanced notice to the entity. There will usually be advanced request for documentation and survey material from the covered entity so that the auditor can best use their time onsite to focus in on what they need to do and the people they need to talk to onsite. And then, as is typical following the onsite visit, the auditors, if they need to, will collect more information. They will complete their draft report. Typically the draft report is shared with the covered entity before it’s final, and the covered entity’s responses to the findings of the auditor would be incorporated as part of the final audit report.

We haven’t decided that (publishing results publicly) yet. Part of this whole endeavor is to have an evaluation component where we can be assured that the information that we are getting through this audit process is accurate and meaningful.

That said, whether we do it in summary form or publish the individual report similar to the way that the inspector general does with their audit materials still needs to be worked out. I think that we will be looking at that very closely as part of our evaluation criteria.

So audits will be onsite and the organization will have advanced notice. Draft reports will be prepared prior to publication. It is not clear if the results will be published for each audit or just a summary will be published. Will this turn into another wall of shame?

And finally, McAndrew gives insight to organizations of how to prepare for the coming audits:

But this is certainly an opportunity for the covered entities to review their policies and procedures to make sure that they are complete and up-to-date. Also, the way that they are managing the information, whether it’s in computerized files or good old-fashioned paper records, make sure that they are fully documenting what’s being done with the information and how it’s being managed and safeguarded. The [HIPAA] security rule has its own requirements for risk analysis and risk management programs. …

Through the experience that we’ve been having with covered entities on breaches and incident response plans, [those plans] need to be up-to-date and flexible, as well as emergency backup systems. I think this is just another opportunity for covered entities to take a moment from their busy, busy days and do a self-assessment. We think that this will help them down the road in terms of building their own capacity for a robust compliance program, training of individuals and making sure that there is awareness throughout the entity of their security and privacy rules and responsibilities.

So she recommends:

  • Creating or reviewing the appropriate policies and procedures
  • Preforming a risk assessment and well as a risk management program (implementing the results of the risk assessment)
  • Creating incident response plans
  • Training employees and implementing an employee awareness program

Good advice for every organization!

Tags: HIPAAPolicies and ProceduresRisk AssessmentSecurity Training
No Comments
Share
0

You also might be interested in

Introducing HIPAA Secure Now!

Feb 13, 2011

We are proud to announce the launch of the HIPAA[...]

Why perform a Risk Assessment?

Feb 15, 2011

A Risk Assessment is required in order to comply with[...]

Employee training might produce the best security ROI

Employee training might produce the best security ROI

Feb 21, 2011

There are countless security products on the market today. You[...]

Leave a Reply Cancel Reply

Recent Posts

  • HIPAA Legal Reminder
  • HIPAA Security Policies
  • Restructuring the OCR
  • HIPAA: P for Portability
  • OCR Healthcare Report Released

Recent Comments

  • Milan on PHI or PII – What’s the Difference?
  • Automatic Backlinks on Free HIPAA Security Training!
  • Lisa Porter on Free HIPAA Security Training!
  • Roseanne ruiz on Health Apps & HIPAA
  • Roseanne ruiz on PHI or PII – What’s the Difference?

Archives

  • March 2023
  • February 2023
  • January 2023
  • December 2022
  • November 2022
  • October 2022
  • September 2022
  • August 2022
  • July 2022
  • June 2022
  • May 2022
  • April 2022
  • March 2022
  • February 2022
  • January 2022
  • December 2021
  • November 2021
  • October 2021
  • September 2021
  • August 2021
  • July 2021
  • June 2021
  • May 2021
  • April 2021
  • March 2021
  • February 2021
  • January 2021
  • December 2020
  • November 2020
  • October 2020
  • September 2020
  • August 2020
  • July 2020
  • June 2020
  • May 2020
  • April 2020
  • March 2020
  • February 2020
  • January 2020
  • December 2019
  • November 2019
  • October 2019
  • September 2019
  • August 2019
  • July 2019
  • June 2019
  • May 2019
  • April 2019
  • March 2019
  • February 2019
  • January 2019
  • November 2018
  • October 2018
  • September 2018
  • August 2018
  • July 2018
  • June 2018
  • May 2018
  • April 2018
  • March 2018
  • February 2018
  • January 2018
  • December 2017
  • November 2017
  • October 2017
  • September 2017
  • August 2017
  • July 2017
  • June 2017
  • May 2017
  • April 2017
  • March 2017
  • February 2017
  • January 2017
  • December 2016
  • November 2016
  • October 2016
  • September 2016
  • August 2016
  • July 2016
  • June 2016
  • May 2016
  • April 2016
  • March 2016
  • February 2016
  • January 2016
  • December 2015
  • November 2015
  • October 2015
  • September 2015
  • August 2015
  • June 2015
  • May 2015
  • April 2015
  • March 2015
  • February 2015
  • January 2015
  • December 2014
  • November 2014
  • October 2014
  • September 2014
  • August 2014
  • July 2014
  • June 2014
  • May 2014
  • April 2014
  • March 2014
  • February 2014
  • January 2014
  • December 2013
  • November 2013
  • October 2013
  • September 2013
  • August 2013
  • July 2013
  • June 2013
  • May 2013
  • April 2013
  • March 2013
  • February 2013
  • January 2013
  • December 2012
  • November 2012
  • October 2012
  • September 2012
  • July 2012
  • June 2012
  • May 2012
  • April 2012
  • March 2012
  • February 2012
  • January 2012
  • December 2011
  • November 2011
  • October 2011
  • September 2011
  • August 2011
  • July 2011
  • June 2011
  • May 2011
  • April 2011
  • March 2011
  • February 2011

Categories

  • Backup & Disaster Recovery
  • Business Associates
  • Client News
  • Download
  • Healthcare Industry
  • HIPAA
  • HIPAA Audits
  • HIPAA Violations
  • HSN News
  • Legal
  • MACRA
  • Policies and Procedures
  • Press Release
  • Remote Workforce
  • Risk Assessment
  • Scams
  • Security
  • Security Reminders
  • Security Training
  • Telehealth
  • Uncategorized
  • Webinar
  • Website

Meta

  • Log in
  • Entries feed
  • Comments feed
  • WordPress.org

Contact Us

  • HIPAA Secure Now
  • 55 Madison Ave, Suite 400 Morristown, NJ 07960
  • (877) 275 - 4545
  • info@hipaasecurenow.com

Find us on Social Media

Recent Posts

  • HIPAA Legal Reminder March 28, 2023
  • HIPAA Security Policies March 21, 2023
  • Restructuring the OCR March 14, 2023
  • HIPAA: P for Portability March 7, 2023
  • OCR Healthcare Report Released February 28, 2023

Subscribe to our Newsletter

  • Hidden

© 2023 · HIPAA Secure Now!

Prev Next