Summary of the October 2023 OCR cybersecurity newsletter

In October 2023, the OCR released a cybersecurity newsletter on the role of sanction policies for HIPAA compliance. The newsletter provided guidance on the best use of sanction policies within healthcare organizations to ensure compliance with HIPAA's regulations. This summary provides the highlights from the newsletter, shedding light on the role of sanction policies in upholding patient privacy and data security. 

What are sanction policies?

Sanction policies, as discussed in the OCR's recent newsletter, are established measures and penalties designed to enforce compliance with HIPAA regulations. 

These policies encompass:   

• Fines
• Disciplinary actions
• Training requirements to deter and address violations of HIPAA rules

Related: HIPAA compliant email: the definitive guide

How HIPAA rules apply to sanction policies 

HIPAA's Privacy Rule and Security Rule require that covered entities and their business associates ensure the compliance of their workforce members with the established regulations. 

Healthcare organizations must adopt written policies and procedures and sanction individuals who breach these guidelines. These aspects of HIPAA are highlighted in the newsletter article as the foundation of a secure and compliant healthcare environment. 

The functions of a sanction policy

According to the OCR newsletter, sanction policies serve a dual purpose within healthcare data security:

Firstly, they act as a deterrent. These policies foster a culture of adherence to the rules by imposing consequences for noncompliance with data security policies and procedures. When workforce members understand that violations come with substantial repercussions, they are more inclined to follow the established guidelines diligently. 

Additionally, educating and training employees on sanction policies significantly boosts their awareness of the significance of compliance and enhances their vigilance concerning cybersecurity threats.

Crafting an effective sanction policy

According to the OCR, one of the remarkable features of a sanction policy is its adaptability. HIPAA allows covered entities to customize these policies to suit the unique needs of their organization. While HIPAA doesn't prescribe the exact penalties or sanctions to be employed, some considerations should be taken into account when crafting an effective policy: 

• Formal documentation: Sanction policies should be documented formally, outlining the process for implementing sanctions. 
• Acknowledgment: Require workforce members to acknowledge that violating the organization's HIPAA policies or procedures may result in sanctions.
• Record-keeping: Maintain detailed records of the sanction process, including personnel involved, procedural steps, timeframes, reasons for sanctions, and the final outcome of any investigation. Retain these records for at least six years.
• Appropriateness: Ensure that the sanctions are appropriate to the nature of the violation.
• Variability of sanctions: Create sanctions that vary depending on factors such as the severity of the violation, whether the violation was intentional or unintentional, and whether the violation indicated a pattern or practice of improper use or disclosure of protected health information (PHI).
• Range of sanctions: Create a range of sanctions, from warnings to termination, to address different types of violations and the severity of each.
• Providing examples: Offer examples of potential violations of policy and procedures to help workforce members better understand their obligations.

Consistent execution of sanction policies

The OCR states that "for these policies to be truly effective, they must align seamlessly with an organization's general disciplinary procedures.". The individuals or departments responsible for implementing sanctions must work together when necessary. Moreover, healthcare organizations must apply sanctions consistently throughout the organization, treating all workforce members equally, regardless of their roles or positions.