Systemic noncompliance is a repeating pattern of organization operations violations, including inadequate risk analysis, insufficient security measures, and a failure to respond to ePHI security changes. It is an ongoing and widespread issue.
HIPAA Rules and systemic noncompliance
Systemic noncompliance could involve recurring violations or lack of consistency in processes, policies, and security measures mandated by each rule.
HIPAA Privacy Rule
Systematic noncompliance with HIPAA Privacy Rule can involve:
- Repeated unauthorized disclosures of PHI.
- Lack of administrative procedures and policies for patient privacy.
- Consistent failure to conduct risk assessments related to PHI protection.
HIPAA Security Rule
HIPAA Security Rule requires implementation and maintenance of necessary safeguards to protect ePHI. Noncompliance can be identified through a lack of risk analyses, inadequate security measures, deficiencies in monitoring system activities, or non-adherence to related policies and procedures.
HIPAA Breach Notification Rule
Within the HIPAA Breach Notification Rule, systemic noncompliance might be seen in a recurring failure to identify, assess, and report breaches of PHI or ePHI. This could include multiple instances of delayed or improper notification to affected individuals or entities, a pattern of insufficiently addressing breaches, or consistent inadequacies in maintaining the required documentation related to breach incidents.
See also: Understanding HIPAA violations and breaches
How to address and rectify systematic noncompliance
Conduct comprehensive assessments
Start by conducting thorough risk assessments and audits across the organization. Identify vulnerabilities, gaps, and noncompliance areas within the HIPAA Privacy, Security, and Breach Notification Rules framework. This involves examining policies, procedures, technical safeguards, and staff training.
Implement corrective measures
Develop a detailed corrective action plan that addresses the identified areas of noncompliance, focusing on implementing necessary security measures, policies, and procedures to rectify deficiencies. It should cover areas such as risk management, regular review of security activities, and system adjustments in response to changes affecting the security of health information.
Engage in continuous improvement
Foster a culture of continuous improvement. Encourage feedback, internal audits, and regular reassessment of compliance efforts to ensure that systems evolve to meet the changing landscape of healthcare regulations and technology.
Utilize HIPAA compliant software
Utilize HIPAA compliant emails designed to meet HIPAA compliance standards for handling, storing, and transmitting sensitive health information. This creates a convenient and efficient way of managing compliance within healthcare organizations.
See also: How to be HIPAA compliant without worrying about HIPAA compliance
Kirsten Peremore
