The following are identified by HHS OCR as elements of an effective compliance program. Please check of as applicable to self-evaluate your practice or organization.
❑ Security Risk Assessment
❑ Privacy Standards Audit (Not required for BAs)
❑ HITECH Subtitle D Privacy Audit
❑ Security Standards Audit
❑ Asset and Device Audit
❑ Physical Site Audit
❑ Have you documented all deficiencies?
❑ Are these remediation plans fully documented in writing?
❑ Do you update and review these remediation plans annually?
❑ Are annually documented remediation plans retained in your records for six (6) years?
❑ Do you have documentation of their training?
❑ Is there a staff member designated as the HIPAA Compliance, Privacy, and/or Security Officer?
❑ Have all staff members read and legally attested to the Policies and Procedures?
❑ Do you have documentation of their legal attestation?
❑ Do you have documentation for annual reviews of your Policies and Procedures?
❑ Do you have Business Associate Agreements in place with all Business Associates?
❑ Have you performed due diligence on your Business Associates to assess their HIPAA compliance?
❑ Are you tracking and reviewing your Business Associate Agreements annually?
❑ Do you have Confidentiality Agreements with non-Business Associate vendors?
❑ Do you have the ability to track and manage the investigations of all incidents?
❑ Are you able to provide the required reporting of minor or meaningful breaches or incidents? ❑ Do your staff members have the ability to anonymously report an incident?
* AUDIT TIP: If audited, you must provide all documentation for the past six (6) years to auditors.
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This checklist is composed of general questions about the measures your organization should have in place to state that you are HIPAA compliant, and does not qualify as legal advice. Successfully completing this checklist does not certify that you or your organization are HIPAA compliant.