Preparing for a HIPAA audit is vital for healthcare organizations. Sure, these organizations understand that they may face a HIPAA audit, but often let preparation for such an event fall to the bottom of their priority list. It is important to ensure your organization is prepared prior to receiving notification of a forthcoming audit. An article on Health Data Management explains why these preparations are so important.
What happens if an organization is not prepared for an audit?
Lack of preparation in facing an audit is very easily detected by an auditor. If you are left scrambling to develop policies and procedures for how your organization protects health information, chances are the rush job will be visible in your documentation.
The best solution is for organizations to expect to be audited by having a plan in place in case the incident were to occur. According to Deborah Gersh, a partner and co-chair in the healthcare practice at Chicago law firm, Ropes & Gray, it is also important to develop a plan on how to deal with a breach if one were to occur.
What happens when a breach occurs?
The Health and Human Services Office for Civil Rights expects that when a breach occurs where devices are stolen, healthcare organizations complete the following:
- File a police report
- Determine if the stolen device was encrypted
- If the stolen device was not encrypted, determine what data was compromised
- Mitigate the breach and protect affected individuals
- Develop and implement an updated data protection plan
“Protection plans are not just about policies and procedures, but about employees understanding what specific roles they will play if a breach occurs.”
-Deborah Gersh
Gersh also says that organization’s chief information officers, security officers and privacy officers should all know and understand their job responsibilities, including their vital roles in the event of a breach. Gersh believes these individuals should know how to answer the following questions:
- Who contacts the police?
- Who files a report?
- Who shuts down the system and in what order?
- Who determines which data was compromised?
- Who compiles the data to determine who gets notified about the breach?
It is important for organizations to have a plan in place for specific types of breaches, whether it be a hacker infiltrating your data networks or a laptop being stolen. According to Gersh, these documents will act as “an organization’s ‘lifeline of evidence’ to present to OCR or the state if the organization experiences another incident in the future.”
“That plan should include increased breach and security awareness, through which everyone in the organization is constantly aware of suspicious behavior, and knowing who the privacy and security officers are when they want to report something.”
Another important warning Gersh provides? Do not be fooled into thinking you have 60 days to deal with a breach before you must report it! Although the federal timeline for reporting a breach may be 60 days, states often have shorter time frames, with some states requiring healthcare organizations to report breaches within 10 days.
Where do organizations get in the most trouble during a HIPAA audit?
Lack of documentation is a major red flag for auditors! Despite the fact that organizations make efforts to demonstrate they have a plan in place, if proper documentation is not in place to show an auditor, the efforts become completely negated.
Organizations are often training their employees on HIPAA requirements, but have no documentation of the training to prove to auditors that they are doing this.
Organizations may also not have proper documentation of their business associates.
“If a business associate has a breach and it is their fault, there should be documentation that that business associate will be responsible to pay for remediation.”
-Deborah Gersh
What is the worst thing an organization can do?
Not having a comprehensive risk analysis puts an organization in extreme jeopardy, resulting in sanctions by regulators. While the thought of performing a risk analysis may seem overwhelming, there is help available to assist you with this task!
The big takeaway
While it may seem time-consuming and costly, it is essential that your organization view HIPAA compliance as a top priority. Ensuring proper documentation including policies and procedures are in place and risk analysis are being performed will greatly reduce your risk in an audit situation. The time to prepare for a HIPAA audit is now!
“You’re going to do it one way or another.”
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