HIPAA Audit: Compliance for Security

The HIPAA Security Rule establishes very clearly the requirements for the Risk Management implementation specification, the Audit Controls standard and the Evaluation standard:

Risk Management Implementation Specification

Audit Controls Standard

Evaluation Standard

The Risk Management standard requires that organizations on a regular basis identify, select, and implement controls, countermeasures, reporting and verification to achieve an appropriate level of risk at an acceptable cost.

Organizations must also repeat the process of identification of all vulnerabilities to electronic PHI as well as other information assets and determine appropriate security measures to reduce risks to a reasonable and appropriate level.

All organizations should go beyond just meeting HIPAA Security Rule compliance requirements. The compliance requirements are limited to electronic PHI. Organizations must evaluate their security requirements for not just all PHI, but all information assets. The requirement for evaluating if compliance requirements have been met may be done internally or with an external resource or jointly.

The Security Rule requires that covered entities periodically conduct an evaluation of their security safeguards to demonstrate and document their compliance with the entity’s security policy and the requirements of the Security Rule.

Objective of HIPAA Audit and Evaluation for Compliance

Risk Management

The NIST defines risk as the net negative impact of the exercise of vulnerability, considering both the probability and the impact of occurrence. Risk is a function of the likelihood of a given threat-sources exercising a particular potential vulnerability, and the resulting impact of that adverse event on the organization. Risk management is the process of identifying risk, assessing risk, and taking steps to reduce risk to an acceptable level.

Security professionals generally define risk management as a process for identifying, selecting, and implementing controls, countermeasures, reporting, and verification to achieve an appropriate level of risk at an acceptable cost.

Audit Controls

Organizations will need to review mechanisms that must be deployed to record and examine system activity to determine suspicious data activities. The audit capability must be such that it enables tracing not just to the device but also to the user. The security policy must hold individuals responsible for their actions. The policies lead to procedures to follow in the event of audit alarms or discrepancies.
Audit controls may apply to a system, a network, an application or any other technical processes. The covered entity should specify how long the organization would retain the audit log data. The required retention period for the audit log data should be adequate to investigate instances of inappropriate access.

The organization should define who may access the systems audit log data and provide for secure storage and protection of the system log data, especially for data which contains protected health information. Audit trails may become evidence in legal proceedings, so care should be taken to protect their integrity in order to preserve their usefulness for such purposes.

Evaluation

It is required that covered entities periodically conduct an evaluation of their security safeguards to demonstrate and document their compliance with the entity’s security policy and the requirements of the Security Rule. Covered entities must assess the need for a new evaluation based on changes to their security environment since their last evaluation. This evaluation may be performed internally or by an external accrediting agency, which would be acting as a business associate. The evaluation would be to both technical and non-technical components of security.

Strong audit trails are a critical component of an organization’s security strategy and help the entity ensure the confidentiality, integrity and availability of e-PHI and other vital information and avoid any HIPAA law violations.

Let us help you in completing your HIPAA compliance with an audit.

Please contact us for more information at sales@supremusgroup.com or call (515) 865-4591