Office of Civil Rights Launches Privacy and Security Audits

Section 13411 of the the Health Information Technology for Economic and Clinical Health Act (HITECH Act) requires United States Department of Health & Human Services (HHS) to provide for periodic audits to ensure covered entities and business associates are complying with the HIPAA Privacy and Security Rules and Breach Notification standards.   The HHS Office of Civil Rights (OCR) announced yesterday, November 8, 2011, the launch of long-expected privacy and security audits.

In our blog on July 13, 2011, we posted information concerning OCR’s hiring of contractors to conduct new periodic audits of covered entities and business associates to ensure compliance with the Privacy and Security Standards found in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as amended by the HITECH Act. Yesterday, OCR announced a pilot program to perform up to 150 audits to assess privacy and security compliance. Audits conducted during the pilot phase will begin in November 2011 and conclude by December 2012.

The initial 150 audits will focus on covered entities, and the audits will begin this month and end by December 2012. Business Associates may have a brief respite but should expect to be the target of future audits.

OCR’s stated goals of the audits are to “examine mechanisms for compliance, identify best practices and discover risks and vulnerabilities that may not have come to light through OCR’s ongoing complaint investigations and compliance reviews.” OCR will “share best practices gleaned through the audit process and guidance targeted to observed compliance challenges.”

Covered entities will be notified in writing if selected for an audit and should be on the lookout for these notices because selected entities have only a short period of time, 10 business days, in which to respond and provide any requested information. After the initial request for information, auditors may conduct onsite audits at an organization. Covered entities will receive 30 to 90 days advance notice of an onsite visit, and auditors expect to spend three to ten days onsite reviewing records, policies and practices. Prior to an auditor’s submission of a final report to OCR, the covered entity will have an opportunity to provide written comments on the auditor’s findings.

Click here to link to OCR’s website with additional details concerning the OCR HIPAA Audit Program.

Leave a reply. Please note that although this blog may be helpful in informing clients and others who have an interest in information privacy and security, it is not intended to be legal advice. The information on this blog also should not be relied upon to form an attorney-client relationship.

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