The Ultimate HIPAA Compliance Checklist

The Health Information Portability and Accountability Act (HIPAA) is a landmark healthcare legislation, transforming the way organizations handle sensitive data surrounding a patient’s medical care. Covered entities that interact with protected health information (PHI) most closely are required to abide by all pertinent regulations within HIPAA requirements, while business associates may only need to comply with certain portions of the legislation. 

In both cases, violating HIPAA regulations can be a serious offense, resulting in costly fines — and even imprisonment. The importance of adhering to all of its applicable guidelines makes having a HIPAA compliance checklist a must for both covered entities and business associates, so we’ve provided one for you here. In this ultimate HIPAA compliance checklist guide, we’ll look at the essential role it plays for healthcare providers, what your checklist should contain, and how Consensus can help you get there. 

The Importance of Compliance for Healthcare Providers

Maintaining HIPAA compliance is critical for healthcare providers. Not only can violations lead to heavy financial penalties, but disclosing important PHI could create distrust in your organization as well as the violation of patient confidentiality. Some employees could even face jail time for willful, negligent violations, and in egregious instances, entire covered entities could be shut down. The result: Maintaining your compliance with HIPAA guidelines isn’t optional — it’s a necessity. 

The Perfect HIPAA Compliance Checklist

Organization is essential for effective operations within the healthcare industry, especially for adhering to the many HIPAA requirements that exist. Identifying your PHI, reviewing your policies, strategizing to form an effective risk management methodology, and maintaining thorough documentation are just a few steps that you’ll need to practice along the way. 

To help you keep track of it all, create a HIPAA compliance checklist that contains all of the essential components. Here’s what your compliance plan should entail.

Identify the Type of Protected Health Information (PHI) Handled

You can’t know what data to protect until you know what data you have. Your organization can have multiple types of PHI, some of which will need to be guarded differently than others. 

For example, electronic PHI (ePHI) should be protected by technical safeguards such as antivirus software and the proper data storage solutions. On the other hand, physical PHI such as paper documents will be protected by physical safeguards such as locking storage bins and storing medical records in places where they can’t be accessed without proper authorization. Some identifiable health information (IHI) may not contain data on a patient’s medical condition, but rather their identity, and must be protected as well. 

Ensure Patients’ Rights Regarding Their PHI

Another important part of your HIPAA compliance checklist is ensuring that your patients’ PHI rights are preserved. Patients’ rights are at the forefront of HIPAA requirements, and protecting them is not only a legal obligation, it’s a matter of good business practice. 

HIPAA emphasizes patient rights in many ways, so organizations must familiarize themselves with the policies they must follow. Some of the most common HIPAA patient rights provisions concern: 

• Access: Patients should be able to access their PHI data upon request.
• Transparency: Patients should be made privy to who has their PHI data.
• Protection: Only authorized third parties should be able to access a patient’s PHI data — and only with their informed consent. 
• Reporting: Whether a breach occurs at the covered entity or business associate level, patients should be promptly notified if their PHI data is leaked.

Despite their many different forms, HIPAA patient rights regulations essentially come down to ensuring that patients can know what their PHI data consists of, can modify it as needed, are aware of who has access to it, and are aware if a breach has occurred.

Review and Update Privacy Policies Regularly

Your privacy policies explain to your patients how their healthcare-related data is used, so they should be kept current with your existing PHI practices. To make sure that your privacy policies adhere to HIPAA guidelines, thoroughly review your existing ones and modify any outdated portions so that they reflect the most recent regulations. Also, schedule them for a periodic review to ensure that they stay current. 

Conduct a Risk Analysis of PHI Handling

Certain parts of your infrastructure may be more vulnerable to a breach than others, so certain types of PHI can have varying risks of being exposed. Conducting a risk assessment can help identify any weak points in your health information stack and can show you where the potential risk is greatest. A typical HIPAA risk assessment can consist of:

• Identifying how your PHI could be compromised by an incident such as a data breach or unauthorized physical access
• Evaluating the probability of such a compromise occurring
• Assessing the impact that the event would have both on your patients and your organization
• Mitigating the likelihood that an event would occur

Once you’ve seen the results of your risk analysis, you then know how best to shore up your PHI infrastructure, keeping you HIPAA compliant.

Develop a Risk Management Strategy

Your risk analysis won’t mean much if you don’t follow it with a practical strategy for managing the risks you uncover. Developing a risk management strategy is key to minimizing the impact of a breach and even to preventing one from occurring in the first place. Some components of a risk management strategy might include:

• A thorough description of how to respond to each event that your risk analysis revealed
• Creating a reporting hierarchy outlining the roles and responsibilities that each responder should play in order to minimize any confusion
• Training and educating existing staff members on proper PHI practices

Another way to form a risk management strategy is to consult a compliance liaison, which can also help demonstrate your initiative in adhering to HIPAA guidelines.

Establish a Breach Notification Protocol

A core component of your risk management strategy is letting the right people know when a breach has occurred. Implementing a breach notification protocol can help streamline communication and avoid errors in the high-stress event of a breach. Some parties to include in your breach notification protocol are:

• Other covered entities
• Any pertinent business associates
• Regulatory bodies such as the Office of Civil Rights (OCR)
• The patient whose PHI data was compromised

Another benefit of creating a breach notification protocol is that it can improve your efficiency during remediation and reporting when security incidents arise. In addition to which parties should be notified, it should also contain policies such as how soon they should be notified and by what means, thus creating a clear framework that will help you maintain your compliance. 

Train Staff on Breach Detection and Reporting

HIPAA contains many compliance requirements, so it’s important that your staff be properly trained on how to adhere to those that apply. Education is essential for helping your staff implement best HIPAA security practices, so be sure to provide thorough training on:

• Your existing HIPAA policy
• How to transmit, store, and delete PHI data 
• The security standards that apply to their respective departments
• Proper log-in/off and password creation processes
• How to identify the signs of a breach
• Whom to report to should a breach occur

By training your staff on how to prevent, detect, and respond to a breach, you’ll form a more circumspect HIPAA security policy and better keep your compliance obligations.

Maintain a Log of All Identified Breaches

In today’s constantly evolving threat landscape, breaches are bound to occur. When they do, an important part of adhering to HIPAA guidelines is documenting them promptly after they happen. This will demonstrate your effort towards transparency and effective remediation and that you’re working toward adhering to the HIPAA security rule.

Document All HIPAA Compliance Efforts

In addition to documenting any security incidents that have occurred, you should also document the efforts you make in keeping compliance. Some things you should document are:

• Any physical, technical, or administrative safeguards that you’ve implemented to keep PHI data secure
• Your medical record storage policy
• The technologies you’re using to conduct your healthcare operations, and if they’re HIPAA compliant, such as EHR systems, CRM software, and HIPAA-compliant digital faxing solutions 
• An inventory of all your PHI, IHI, and ePHI data 
• Your breach reporting protocol

The saying in the healthcare industry is “If you don’t document it, it didn’t happen.” That certainly holds true for your HIPAA compliance, so be sure to document the efforts you’ve made to adhere to the regulations.

Retain Records of Compliance Activities and Audits

Documentation is only part of your HIPAA compliance efforts — you must also maintain important compliance-related records as well. Some documents, such as audits and compliance consultations, demonstrate your efforts to play by the rules, while others, such as a patient’s medical record, must be stored for a fixed period of time — often at least six years, depending on the circumstances. 

Ensure All Vendors Are HIPAA Compliant

To be fully compliant, it’s not enough that your organization abide by HIPAA’s guidelines. Your business associates must be compliant as well. Working with HIPAA-compliant business associates helps prevent data from being leaked or breached at the third-party level, reducing your chance of a violation yourself. It also can boost your healthcare operability by ensuring that all data is transmitted smoothly, and since covered entities can be held responsible for their business associates’ breaches, doing business with the right partners is a must. 

Use Consensus Cloud and Enhance Your Compliance Strategies

Whether you’re a covered entity such as a health plan or a business associate who works with PHI data, maintaining your organization’s HIPAA compliance is foundational to its operations. It can involve multiple steps, including transparency, thoughtful safeguard implementation, and thorough documentation, but the consequences of failing to maintain your HIPAA compliance are too great to risk any oversights. That’s why a HIPAA compliance checklist is a must.

At Consensus, we produce digital faxing solutions that the healthcare industry relies upon to perform its most basic business processes. We offer a host of products including Consensus Cloud Solutions, which offers a safe, HIPAA-compliant way to store, create, and transmit important healthcare documents. Our solutions can elevate your interoperability and help you maintain your HIPAA compliance, so request a demo today to see what we can do for you.