Staying HIPAA compliant as a healthcare facility is a difficult task, not only because the Health Insurance Portability and Accountability Act was enacted first in 1996, but also because many of its rules that were gradually added are confusing and requirements, vague. As a result, there is going to be rightful paranoia from you about whether or not your health business is up to code.
So how can you, as the manager, determine your facility needs professional help? You can start by reading below to see five signs that will help you evaluate if your healthcare business needs a HIPAA compliance consultant immediately.
5 Ways Human Error Requires HIPAA Compliance Consulting
Human error is the primary cause of HIPAA policy violations and data breaches, whether it’s on the end of your employees, the end of the owners and employees of organizations and businesses you hire, or even due to your own unintentional mistakes. No owner and manager deliberately risk their business by violating HIPAA regulations, but here are five ways human error can make its way through.
Your Training Program Lacks HIPAA Risk Assessments
You can’t expect your employees to comply with rules they don’t know about, especially for regulations that are always changing, like HIPAA’s. Effective compliance training is the first step towards an excellent compliance program.
Your training program should be based on any risk assessments associated with HIPAA’s security, privacy, and breach notification rules, at the very least. So, taking HIPAA’s own training course is an excellent way to make sure you and your staff won’t be missing anything important. And since documentation is so important for liability protection, make sure your document your staff’s attestation to the policies.
Not all HIPAA requirements and practices are applicable for every department in your business. Make sure everyone has the general training in addition to the policies that do apply to them. Forcing everyone to suffer through a fully comprehensive form of HIPAA training where the bulk of the information doesn’t apply to them will only waste everyone’s time. In addition, not all of the annual Officer of Civil Rights (OCR) audits and assessments are required of your business, so focus your attention on those that apply.
Once everyone is properly trained, include periodic reminders via emails or physical posters to maintain security awareness.
Your Facility Lacks a HIPAA Compliance Officer
Having a quality HIPAA compliance training program won’t keep your business safe if there isn’t someone whose primary role is to ensure the HIPAA privacy and security rules are being met and enforced. If you didn’t know, HIPAA requires having a compliance officer if you are a covered entity, that is, a healthcare provider, health plan provider, or healthcare clearinghouse.
You’re kept busy enough with managing the day-to-day operations, so how certain can you be that your healthcare facility is compliant without someone who can give you regular reports?
In addition to making sure everyone in your business, and your business associates are compliant with HIPAA, a compliance officer will conduct annual HIPAA training with the rest of the staff with the annual HIPAA checklist, run IT backgrounds, audit systems.
Make sure you prevent any inhibitions to their job by giving them the right HIPAA resources, training, and authority to do their job well. One such resource is the list of the vendors and suppliers you conduct business with and their business associate agreements (BAA) that document the security measures they each have in place.
Your Security Measures Don’t Meet Current Standards
It’s crucial for you to have regular and thorough Security Risk and Gap Assessments to make sure your safeguards and security measures are up to date with the latest security and privacy requirements from HIPAA. They show if there is any difference, or gaps, between where your information security is currently at and where it needs to be.
Successful security risk assessment models will accomplish four things:
- Identify all of the most crucial technology assets (equipment and systems responsible for storing and interacting with data) and create a “risk profile” that makes it clear which systems and tech equipment are at the greatest risk of a security breach.
- Assess the security risks and construct an efficient and effective way of containing and minimizing those risks. The model should take into account available time and resources, the critical use and vulnerabilities of the assets, and mitigation control measures.
- Put the mitigation plan into action with enforced security measures for each asset risk.
- Have preventative measures in place, such as system tools and processes, that will minimize any weaknesses in your assets in the future.
Procrastinating your security risk and gap assessments will show your current security measures are below the updated ideal standards. Being caught without the ideal protective levels and risk prevention would result in a crushing fine for you.
Third Parties You Hire do Not Have BAA Contracts
Anyone who handles your patients’ personal health information, whether they are part of the healthcare industry or not, must comply with you on the use and accessibility of PHIs according to the dictation of HIPAA standards. This compliance on their behalf comes in the form of Business Associate Agreements (BAA) that shows your partners agree to maintain the security standards that HIPAA requires. If they don’t comply with your requests, it’s better to find another vendor or service provider than risk a security breach.
Not only does this create an understanding with any third parties about the security measures you need to have taken, but it also outlines each party’s responsibility with PHIs, clearly showing where each party is accountable if there is a breach. If third parties don’t have the BAA contracts, you are the one who takes all the blame.
Third parties that should have a BAA include
- Company lawyers
- Company accountants & billing companies
- Email encryption service companies
- Data storage/medical record companies
- IT contractors
It’s especially important that those partners that store and transfer PHI data or encode it on a daily basis, like the storage companies and encryption services, have the BAA, which brings us to our last clue telling you that you need HIPAA compliance consulting right now.
Your Online PHI Data Storage Has Minimal Security
IT systems have been the biggest source of confusion in compliance to HIPAA. Back in 1996, IT systems weren’t the security concern they are today with PHIs. Now, HIPAA has numerous recommendations for the protection of electronic PHIs (ePHI) that every member of your staff can do, such as
- Logging off of their work stations when leaving
- Never leaving PHIs unattended
However, when it comes to making your IT systems and online business compliant with HIPPA, the online data must be protected through the following options:
- Hierarchy of authorized personnel
- Backed-up data
- Encryption during transport
- Encryption during storage
- Permanent deletion when no longer required
- Make sure the documents cannot be modified
If any of the above problems are what your business is experiencing you need to set up an appointment with a HIPAA compliance consultant as soon as you can. They should evaluate your training program to ensure it’s complete and updated. If any security and compliance gaps are found in your training program, it would be a good idea to let the consultant evaluate other areas of your facility, like your data security or the quality of the work of your current compliance officer.