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The seven building blocks of HIPAA compliance

The seven building blocks of HIPAA compliance

Covered entities are required to ensure HIPAA compliance. The key to maintaining HIPAA compliance is by adhering to HIPAA requirements, ensuring patient privacy, protecting electronic protected health information (PHI), and maintaining the trust of patients. 

 

The building blocks of HIPAA compliance:

  1. Policies and procedures: Covered entities should outline guidelines for privacy practices, security measures, access controls, employee responsibilities, and breach notification. Regularly review and update these policies to stay compliant with changing regulations. The documentation of policies should be easily accessible and readily available to all employees.
  2. Employee training and education: Covered entities should provide regular training on HIPAA regulations, privacy practices, and security measures. Employees should understand their roles and how to handle PHI appropriately. Training sessions should cover patient consent, notice of privacy practices (NPP), and recognizing and reporting potential security incidents or breaches. Maintain records of employee training and ensure that new employees receive training upon joining the organization.
  3. Risk assessments and management: Conducting regular risk assessments helps covered entities identify vulnerabilities and risks to PHI. This includes evaluating physical security, technical safeguards, access controls, and employee practices. Based on the assessment, implement risk management strategies and appropriate safeguards to mitigate risks effectively. 
  4. Business associate management: Covered entities must establish and maintain business associate agreements (BAAs) with external entities that handle PHI on their behalf. Regularly review and assess the compliance of these business associates with HIPAA requirements. Maintain an inventory of business associates and periodically conduct audits or assessments to verify compliance.
  5. Privacy practices and security measures: Covered entities should obtain patient consent for disclosures, limit access to PHI on a need-to-know basis, and establish appropriate safeguards to prevent unauthorized access or disclosures like using HIPAA compliant email. Implement technical, physical, and administrative safeguards to protect electronic PHI. 
  6. Incident response and breach notification: Promptly address security incidents or breaches to mitigate harm. Covered entities should establish procedures for containment, investigation, and breach notification. They must ensure compliance with breach notification requirements, including notifying affected individuals and regulatory authorities. 
  7. Ongoing compliance monitoring and documentation: Regularly monitor and audit systems, policies, and procedures to maintain HIPAA compliance. This includes conducting internal audits, reviewing access logs, and promptly addressing any identified vulnerabilities or non-compliance issues. Maintaining thorough documentation of compliance efforts demonstrates compliance during audits or investigations. This documentation should include policies, procedures, risk assessments, training records, incident response plans, and other relevant documentation.

The key to HIPAA compliance for covered entities is by adhering to HIPAA requirements and ensuring patient privacy through protecting PHI. 

Related: Understanding and implementing HIPAA rules

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