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HIPAA HITECH-Required Audits

HIPAA compliance auditors contracted by the Office for Civil Rights (OCR) will review whether covered entities have corrective action plans in place and if they diligently work to remediate any problems.

Below are the key points of the audits, including some of the major issues on OCR's radar for the industry:

* Incident detection and response (OCR's top issue);

* Access log review;

* Secure wireless network;

* User access and passwords management;

* Theft or loss of mobile devices;

* Up-to-date software; and

* Role-based access (lack of information access management).

Background

OCR awarded KPMG, LLP, an auditing firm, a contract to administer the HIPAA privacy and security compliance audits required by Congress via HITECH. The first phase of the audits-in which OCR plans to visit 150 covered entities-is expected to start this coming fall and end by December 31, 2012.

person holding pencil near laptop computer

OCR is taking a systematic approach to determine which organizations to audit based on risk.

Audits will no longer be driven only by responses to complaints or breaches, but they will be directed at organizations that OCR selects based on an overall risk profile.

OCR says the audits are seen as an opportunity to gather information about exposures in the industry and proactively identify certain issues ahead of time before they result in breaches across the industry. They say that the results of the audit will be a learning opportunity for the entire industry.

Conducting the audits

OCR is working on a model for objectively selecting organizations for audit based on risk factors (e.g., size, type of entity).

The audits will not simply focus on organizations that had an incident. The initial focus will largely be on covered entities.

Entities will receive advanced notice before any audits. And though OCR is budgeted for 150 audits, it's "unlikely" the auditors will get through that many by the end of 2012. OCR plans to release aggregate findings across all audits as a "learning process for the industry".

OCR expects that organizations are performing risk assessments. Risk assessments are not expected to be 'clean,' but it's important that organizations have corrective action plans in place and are diligently working to remediate issues.

If you have any questions regarding your risk assessments and/or the OCR audit program, do not hesitate to call or email us.