Earlier this week, information about OCR Phase 2 HIPAA audits was provided. Today, let’s take a look at how to prepare if your entity is selected for an audit:
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Confirm that a recent comprehensive Risk Assessment has been completed and documented.
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Confirm that all action items identified in the Risk Assessment have received attention and have been completed (or are in the process of being completed).
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Verify that policies are up-to-date, including breach notification procedures, notice of privacy practices, and responses to patient requests.
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Ensure that a current list of business associates (and their contact information) is readily available.
Because Phase 2 does not consist of on-site visits, there will not be an opportunity for dialogue with auditors. Therefore, it is crucial to ensure that documentation alone shows a complete picture of an entity’s compliance efforts. All documents should be carefully reviewed, dated, and signed before turned over to an auditor. While providing extraneous information is not recommended, it is important to double-check that all requested and necessary information is submitted.
Phase 2 audits set to occur in 2016 will focus on the Security Standard’s encryption and decryption requirements, facility access controls, breach reports and complaints. It is never too early to start considering what protocols, training, and procedures will need to be implemented in anticipation of a possible audit related to these items.