The HIPAA Security Rule Checklist helps covered entities, business associates, and other organizations subject to HIPAA meet the requirements of the Security Standard for the Protection of Electronic Health Information (preferably known as the HIPAA Security Act). Compliance with regulatory security standards will reduce the risk of HIPAA violations and data breaches due to human error or malicious actors.
HIPAA Security Rule Overview
HIPAA Security Regulatory Requirements The HIPAA security regulations are contained in Section 164, Subpart C, and include rules, standards, and enforcement requirements intended to ensure the confidentiality, integrity, and availability of electronic protected health information (ePHI) created, collected and protected by covered entities, business partners, and other HIPAA-compliant organizations.
All organizations subject to HIPAA must comply with the Privacy Act’s rules, standards, and implementation requirements. However, because security standards are not technical, organizations are allowed “the easy way” for security measures implemented. The flexibility of the approach extends to how organizations meet the requirements of a “fixable” implementation format.
HIPAA Security Rule Checklist: What Is It?
The HIPAA Security Law Checklist summarizes the key laws, standards, and implementation requirements that apply to most organizations. The reason the checklist is a summary is that there is no single HIPAA Security Act checklist that can be applied due to the wide variety of organizations that must comply with the Security Act and the flexibility of Security’s approach. . It is allowed by law. It meets the needs of each organization.
Organizations should use this HIPAA Security Standards Checklist as a basis for their own checklists. Not only must organizations protect against relevant security threats, but they must also take care to develop a checklist of general requirements (§164.306(a)). It protects the integrity of ePHI and protects against inappropriate uses or disclosures of ePHI that are not permitted or required by the Privacy Act.
The Purpose Of This HIPAA Security Rule Checklist
This HIPAA security rules checklist is intended for all employees who have HIPAA rules responsibilities. Depending on the size of the organization, this may be the HIPAA security officer or a member of the compliance team. If aspects of compliance are outsourced to another party, this HIPAA Security Compliance Checklist can be an excellent guide for IT members. , HR, legal or security teams.
This HIPAA Security Rule Checklist is designed to apply to the types of organizations that can benefit from it: HIPAA-covered entities and business partners, including business partner contractors, personal medical device providers, and working organizations. You may not be a covered entity under HIPAA, but you may qualify under state law (eg, the Texas Medical Records Privacy Act).
Security Rule Compliance: 10 Important Elements
While it is important to review and understand all the laws, standards, and implementation requirements of the Security Act, there are ten important areas of HIPAA security compliance that apply to most organizations.
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The General Rules Of The Security Standard Should Be Read
The general safety rules include the conditions that apply when the track is removed and determine when the installation requirements are appropriate or inappropriate. It is important not to overlook the implementation standards and requirements in this section, as they relate to the rest of the checklist.
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Analyze The Risks Thoroughly
To ensure the confidentiality, integrity, and availability of ePHI, you need to know how and where ePHI is created, collected, stored, and transmitted. For this reason, it is important to identify unauthorized software and applications used by employees (“Shadow IT”) and the systems or devices they connect to.
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All Access To Ephi Should Be Controlled And Monitored
Based on the results of your risk assessment, you will be in a better position to determine what access rights are necessary to ensure that only authorized personnel have access to your ePHI. However, access monitoring is still necessary to identify instances where unauthorized passwords are shared or access credentials are compromised.
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Establish A Training Program And Sanctions Policy
The Security Act requires all organizations to implement a security awareness training program for all employees, regardless of access to ePHI. Organizations must develop and enforce breach policies and security procedures, regardless of whether the breach results in a data breach.
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Ensure That Procedures Are In Place For Reporting Security Incidents
Security laws require organizations to implement policies and procedures to manage security incidents. However, for this standard to be effective, it is important for organizations to recognize security incidents early. For this reason, we recommend that you implement an incident reporting process as soon as possible.
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Operation In Disaster Recovery And Emergency Mode
Most health care providers are required to implement emergency and accident recovery procedures as a condition of participating in Medicare. However, because disasters can affect the operations of health care providers, it is important for all organizations to develop, test, and update operational plans for disaster recovery and emergency mode.
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Agreements Between Business Associates And Subcontractors
The reason we include subcontractors and subcontractors in this HIPAA Privacy Rule checklist is because Privacy Rule §164.504(e) contains important information about how to treat subcontractors and subcontractors when ePHI is disclosed to individual’s third party.
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Assuring Compliance With Security Rules By Configuring Software
Most modern software solutions include features such as data integrity, encryption, and automatic notifications. However, software is not always configured by default to follow security rules. You must review the configuration of computers used to create, collect, store, or transmit ePHI for proper use.
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Maintain The Security Of Facilities, Devices, And Media
It is a good practice to maintain an inventory of the devices and media used to create, collect, store, and transmit ePHI. In addition to protecting devices and media from unauthorized access, the facilities where those devices and media are located must also be protected against unauthorized access and theft.
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Review The HIPAA Security Rule Checklist
The final implementation standard of the Security Act requires organizations to maintain documentation, review it periodically, and update it as necessary in response to environmental or operational changes. In light of the expected changes in 2024, we recommend that organizations schedule a review of their HIPAA Security Rules Checklist within 12 months.
Security Rule Standards In 2024: Expected Changes
In December 2023, the Department of Health and Human Services released the National Cyber Security Strategy, a concept paper that outlines actions to protect the healthcare industry from cyber threats in line with President Biden’s National Cyber Security Strategy.
One of the actions proposed in the concept paper is to update security laws to include new requirements for the internet. Due to the length of time it takes for proposed regulations and changes to existing laws to become final law, it is unlikely that the new cybersecurity regulations will come into force in 2024.
However, there are other legislative changes in the works: It affects your compliance by 2024. This includes, but is not limited to:
- Specify “approved security measures” to be considered when determining civil penalty amounts for HIPAA violations.
- A requirement to include in the public accounting system the disclosure of ePHI for treatment, payment, and health care activities (see 42 USC §17935(c)).
- Penalties for violating HIPAA now apply to unauthorized disclosures of substance abuse patient records protected by 42 CFR Part 2.
- Added a new category of “verified” uses and disclosures to prevent family health care data from being used or disclosed for “non-health” purposes.
Organizations struggling to prepare for these expected changes or develop a HIPAA security compliance checklist are encouraged to seek professional compliance advice.
