The HIPAA Security Rule must be followed by all covered entity organizations that handle electronic protected health information (PHI) and must address HIPAA security. The HIPAA Security Rule applies to health plans, health care clearinghouses, and to any health care provider who transmits health information in electronic form in connection with a transaction for which the Secretary of HHS has adopted standards under HIPAA and to their business associates.  It is the responsibility of these organizations who are focused on HIPAA compliance to safeguard all protected health information and demonstrate this through a carefully crafted HIPAA compliance plan with HIPAA Security Standards and designation of a HIPAA security officer as required by the Security Rule.

Create a Security Plan

The Security rule was adopted to implement provisions of the Health Insurance Portability and Accountability Act (HIPAA). This rule sets the standards for ensuring that only those who should have access to electronic protected health information (EPHI) will have actually have access. The Privacy Rule requires covered entities to have in place appropriate administrative, physical, and technical safeguards and to implement those safeguards reasonably.

HIPAA Security Policy – Topics

  • History of Security Rule
  • General Overview
  • Administrative Safeguards
  • Physical Safeguards
  • Technical Safeguards
  • Organizational Policies and Procedures and Documentation Requirements
  • Security Rule Requirements for Risk Analysis and Risk Management

Our HIPAA Securiy Policies cover all of the important issues which will affect a covered entity or a business associate.

Administrative Safeguards

Security Management Process

  • Risk Analysis
  • Risk Management
  • Sanction Policy
  • Information System Activity Review

Assigned Security Responsibility

Workforce Security

  • Authorization and/or Supervision
  • Workforce Clearance Procedure
  • Termination Procedure

Information Access Management

  • Access Authorization
  • Access Establishment and Modification

Security Awareness and Training

  • Security Reminders
  • Protection from Malicious Software
  • Log-in Monitoring
  • Password Management

Security Incident Procedures

  • Response and Reporting

Contingency Plan

Data Backup Plan

  • Disaster Recovery Plan
  • Emergency Mode Operation Plan
  • Testing and Revision Procedures
  • Applications and Data Criticality Analysis

Technical & Non-technical Evaluation

Business Associate Contracts and Other Arrangements

  • Written Contract or Other Arrangements

Physical Safeguards

Facility Access Controls

  • Contingency Operations
  • Facility Security Plan
  • Access Control and Validation Records
  • Maintenance Records

Workstation Use

Workstation Security

Device and Media Controls

  • Disposal
  • Media Re-use
  • Accountability
  • Data Backup & Storage

Technical Safeguards

Access Control

  • Unique User Identification
  • Emergency Access Procedure
  • Automatic Logoff
  • Encryption and Decryption

Audit Controls

Integrity

  • Mechanism to Authenticate Electronic Protected Health Information

Person or Entity Authentication

Transmission Security

  • Integrity Controls
  • Encryption
HIPAA Security Policies

We offer Security Policies that will help you prepare for Security Rule Compliance. These are easily modifiable for immediate use. They cover all the policies & procedures necessary to be compliant with the Privacy Rule & HITECH Regulations.

Template Security Plans – Contact Us

Contact us for your HIPAA Security Policies

Security Policies

HIPAA Security

HIPAA Compliance policies and procedures must be implemented to ensure compliance with the HIPAA Rules. The policies implement appropriate administrative, technical, and physical safeguards to protect the privacy and security of PHI. This includes all forms of PHI which is either written, verbal or electronic. As a result, a covered entity will have to protect the confidentiality, integrity, and availability of PHI and electronic (e-PHI). In addition to be fully prepared an entity must also perform a full Security Risk Analysis to assess the health and security of their HIPAA program.

Risk Analysis

It is important for all organizations who handle PHI to prepare by performing a Risk Analysis to determine the risks to Protected Health Information (PHI) in their organization. By doing so they can prepare to address any vulnerabilities. The Security Rule provides guidance in this matter and should be addressed by all interested Privacy Officers. An organization that is just getting started with their HIPAA plan may consider a HIPAA Gap Analysis which gives an overview of risk factors.

Appoint a Security Officer

A HIPAA Security Officer, once appointed will oversee the HIPAA Security program. They are responsible for oversight of the program and for tracking, investigating, resolving and documenting all privacy and security complaints and investigative steps taken. They ensure there is no retaliation against any workforce member or other individual for reporting a PHI breach or filing a HIPAA complaint.

Implement a Training Plan

The program must implement a training plan that trains workforce members on the requirements and policies that apply to them in their individual roles. The training program must train all workforce members upon employment on HIPAA and policies and procedures and on a regular basis thereafter. The OCR does not accept the term “Certification,” but rather wants to confirm all personnel have received appropriate training.

Accountability

A HIPAA compliance plan holds providers and workforce members accountable for protecting PHI. Naturally this occurs through its policies, procedures and guidelines. In addition, the plan also outlines the consequences of a PHI breach or any violation of the policies in the compliance plan. By having a plan in place, it will help mitigate any breaches of PHI that might occur in the future. Finally, HIPAA compliance plans also ensure proper training of all workforce members, which includes employees, physicians, volunteers and trainees.

HIPAA Associates Will Help

Our professionals will assist you with all of these important policies and procedures. HIPAA Associates develops and consults on HIPAA compliance plans that include HIPAA privacy and security, policies and procedures and breach reporting requirements in compliance with the HIPAA Rules. Of great importance, HIPAA Associates is always available to assist you when questions arise regarding the HIPAA Rule. HIPAA consulting is the main focus of our organization. We would be happy to discuss with you how we can help with your program.

Frequently Asked Questions:

Do we need a HIPAA Compliance Plan?

Any covered entity that handles protected health information (PHI) must be prepared to protect that information.  This is done by creating and implementing a HIPAA compliance plan with policies and procedures to safeguard PHI.  The plan will outline the steps you will have to take in the event of a breach.  This will ensure that all workforce members are properly trained on how to handle PHI in all its forms.

HIPAA Associates is prepared to create the perfect compliance plan for your organization that has all the necessary policies, procedures and training you will need to keep your PHI safe.

HIPAA Security Compliance

How do I handle a breach?

It is important to follow all the steps to report a breach to the OCR.  Every breach is different and must be handled on a case by case basis.  A full breach analysis must be performed to determine if there was an impermissible use or disclosure that compromises the security of protected health information.

Factors to be addressed are:
1. The nature and extent of the breach including identifiers
2. The unauthorized person to whom disclosure is made
3. Whether the PHI was acquired or viewed
4. The extent to which the risk to PHI has been mitigated.
HIPAA Associates can help your organization through this process to ensure you follow all the important steps.

How to create a Compliance Plan

 

  • Implement Policies & Standards

    Policies and procedures help establish the rules your organization will need to carry out the requirements of federal health care program guidelines.

  • Designate a Compliance Officer

          The compliance officer will be responsible for operating and monitoring the compliance program.

  • Conduct an effective training program

          All personnel should receive training on fraud & abuse laws as well as the compliance program.

  • Develop effective lines of communication

          Employees must have avenues available for reporting concerns internally. Anonymous reporting must be available.

  • Conduct internal monitoring and auditing

          A good program will have an ongoing process to evaluate and assess the organization for inappropriate behavior.

  • Enforce standards of conduct with guidelines

          An organization must have well published standards of conduct. The plan should clearly state the implications and penalties of violating the standards.

  • Respond promptly to violations and take corrective action

          An organization must ensure timely and effective remedial action for offenses.