The following are identified by HHS OCR as elements of an effective compliance program.
Please check off as applicable to self-evaluate your practice or organization
Have you conducted the following six (6) required annual Audits/Assessments?
Security Risk Assessment
Privacy Standards Audit (Not required for BAs)
HITECH Subtitle D Privacy Audit
Security Standards Audit
Asset and Device Audit
Physical Site Audit
Have you identified all gaps uncovered in the audits above?
Have you documented all deficiencies?
Have you created remediation plans to address deficiencies found in all six (6) Audits?
Are these remediation plans fully documented in writing?
Do you update and review these remediation plans annually?
Are annually documented remediation plans retained in your records for six (6) years?
Have all staff members undergone annual HIPAA training?
Do you have documentation of their training?
Is there a Staff member designated as the HIPAA Compliance, Privacy and/or Security Officer?
Do you have Policies and Procedures relevant to the annual HIPAA Privacy, Security, and Breach Notification Rules?
Have all staff members read and legally attested to the Policies and Procedures?
Do you have documentation of their legal attestation?
Do you have documentation for annual reviews of your Policies and Procedures?
Have you identified all of your vendors and Business Associates?
Do you have Business Associate Agreements in place with all Business Associates?
Have you performed due diligence on your Business Associates to assess their HIPAA compliance?
Are you tracking and reviewing your Business Associate Agreements annually?
Do you have Confidentiality Agreements with non-Business Associate vendors?
Do you have a defined process for incidents or breaches?
Do you have the ability to track and manage the investigations of all incidents?
Are you able to provide the required reporting of minor or meaningful breaches or incidents?
Do your staff members have the ability to anonymously report an incident?
Audit tip: If audited, you must provide all documentation for the past six (6) years to auditors.