HIPAA Compliance Audit Services

HIPAA compliance audit services have become a critical component of healthcare organizations’ operations.

HIPAA Audit: Compliance for Security

The Department of Health and Human Services (DHHS) Office of e-Health Standards and Services released a 2-page document with the Sample – Interview and Document Requests for HIPAA Security Onsite Investigations and HIPAA Compliance Audit Reviews.

To download PDF:
Official DHHS released HIPAA Audit Checklist

The Importance of HIPAA Compliance

 HIPAA was enacted to ensure the confidentiality, integrity, and availability of electronic protected health information (ePHI). Our HIPAA Compliance Audit services will help you to comply with HIPAA regulations. HIPAA Audit will help with compliance as it:

  • Protects Patient Information: HIPAA safeguards patient data, ensuring their confidential health information remains secure.
  • Prevents Breaches: Compliance helps avoid breaches of data, which can lead to costly legal consequences and damage to an organization’s reputation.
  • Ensures Trust: Maintaining compliance instills trust in patients, who need to know their data is safe.

HIPAA Compliance Audit Process

Conducting Risk Assessments

The first step for HIPAA Audit is to perform a thorough risk assessment, identifying vulnerabilities and mitigating potential threats.

HIPAA compliance audits are systematic assessments designed to evaluate the adherence of covered entities and business associates to HIPAA regulations. The goal is to identify gaps, vulnerabilities, and areas of non-compliance. These audits are conducted by qualified and experienced professionals who thoroughly examine an organization’s policies, processes, and technology systems.

Benefits of HIPAA Audit

  1. Risk Mitigation: HIPAA compliance audits help identify vulnerabilities and non-compliance areas before they become serious problems. By addressing these issues proactively, organizations can mitigate risks and reduce the likelihood of costly data breaches or fines.
  2. Legal Protection: Compliance audits can help organizations demonstrate their commitment to data security and patient privacy in case of legal disputes or investigations.
  3. Cost Savings: Preventing data breaches and non-compliance issues is more cost-effective than dealing with the fallout of such incidents. HIPAA audits can help organizations avoid hefty fines and legal expenses.
  4. Improved Reputation: Patients want to know that their sensitive information is in safe hands. HIPAA compliance audits help build trust with patients and demonstrate a commitment to their privacy.
  5. Efficiency and Process Improvement: Through audits, organizations can identify areas for process improvement, leading to more efficient operations.

Common Challenges in HIPAA Compliance Audit

Employee Training

Addressing the human element: why training is pivotal in maintaining a compliant and secure healthcare environment.

Evolving Technology

Navigating the challenges posed by technological advancements and staying ahead in the ever-changing landscape.

HIPAA Compliance Audit Best Practices

Continuous Monitoring

Why a proactive approach, including regular audits and monitoring, is key to maintaining compliance in the long run.

Documentation Excellence

Crafting thorough documentation that not only satisfies auditors but also serves as a valuable internal resource.

The HIPAA Security Rule establishes very clearly the requirements for the Risk Management implementation
specification, the Audit Controls standard, and the Evaluation standard:

Risk Management Implementation Specification

This involves employing security measures sufficient to reduce risks and arrest vulnerabilities at a manageable and acceptable level.

Audit Controls Standard

This involves the implementation of both software and hardware, among other procedural mechanisms necessary to analyze information systems or systems using electronic (PHI/e-PHI).

Evaluation Standard

This comprises standard periodic technical and non-technical reviews to assess document compliance with HIPAA Security Rule and the organization’s security policy.

The organization must assess regularly, make identification selections, and implement necessary countermeasures on risk management standards to ensure acceptable security-related costs. This process must be done periodically to ensure that the relevant security measures are implemented so that all risks are manageable and appropriate.

Otherwise, it is highly recommended for an organization to go beyond HIPAA Security compliance and observe other security measures. On the other hand, an entity can have an external source evaluate its compliance requirements or can work jointly.

Most security rules will require covered entities to evaluate their security safeguards periodically to ensure compliance with the organization’s security policies and security rule requirements.

The Goal of HIPAA Audit and Evaluation for Compliance

The HIPAA Audit Objective will comprise of the following activities:

  1. Makes assessments on whether all vulnerabilities have been taken care of
  2. Make verifications on if all the compliance requirements are up to standard.
Item HIPAA Citation HIPAA Security Rule Standard Implementation Specification Implementation
164.308 (a) (1) (i) Security Management Process
164.308 (a) (1) (ii) (B) Risk Management Required
164.308 (a) (8) Evaluation Required
164.312 (b) Audit Controls Required

Risk Management

The main objective of risk management is to employ various security measures necessary to control and reduce risks to an appropriate and reasonable level.

NIST defines risk as its overall negative impact, including its probability and the effect in the event it occurs. Most of the time, a risk is the likelihood of different threat sources exposing the entity’s threats or risks and, in the long run, resulting in adverse repercussions to the organization’s running. Therefore, risk management is the process of assessing and identifying risks and taking action to ensure risks are at a manageable level.

Security professionals define risk management as identifying, selecting, and implementing controls, reports, and countermeasures to ensure the risk levels are commensurate with their budgeted costs.

Audit Controls

The main goal of Audit control is to analyze software, hardware, and other mechanisms responsible for recording and examining activities from information systems that contain or use protected eHealth information.

Most organizations must make relevant assessments and implement mechanisms to record and analyze the system for suspicious activities. The audit controls should trace you to the device and the user, and such individuals should be held accountable. Otherwise, there are policies to take in case of such discrepancies.

The audit control can be used for a network, software application, system, and other technical devices. It usually is up to the entity to determine how long the investigating organization should hold the audit information, and it should be long enough to carry out the necessary investigation and incidents of inappropriate access.

On the other hand, the organization will determine who can access the audit log data in the systems, provide secure storage, and offer protection to the system’s data, especially on protected eHealth information. In addition, audit trails are typically evidence of legal proceedings; hence, they need to be handled with care to preserve their authenticity.


The main aim of this evaluation process is to periodically evaluate the technical and non-technical compliance standards of an entity as indicated under this regulation and, more so, to verify the entity’s adherence to this rule in its response to some of the environmental or operational changes that can affect its protected eHealth information.

This is a requirement for covered entities to periodically evaluate their security safeguards compliance with their security policy and Security rule requirements. Therefore, after assessing changes in an entity’s secure environment, an entity will be required to look into its need for a new evaluation. These evaluations can be done internally or using an external source for technical and nontechnical security components.

The only way to ensure that your entity’s confidentiality, security, and integrity are consistent with e-PHI compliance standards is by observing audit checks for your entity.

HIPAA Audit Checklist released by DHHS’ Office of e-Health Standards and Services

Sample – Interview and Document Request for HIPAA Security Onsite Investigations and Compliance Audit Reviews

Personnel that may be interviewed :

President, CEO, or Director

HIPAA Compliance Officer

Lead Systems Manager or Director

Systems Security Officer

Lead Network Engineer and/or individuals responsible for:

  • administration of systems that store, transmit, or access Electronic Protected Health Information (EPHI)
  • administration systems networks (wired and wireless)
  • monitoring of systems that store, transmit, or access EPHI
  • monitoring systems networks (if different from above)
  • Computer Hardware Specialist
  • Disaster Recovery Specialist or person in charge of data backup
  • Facility Access Control Coordinator (physical security)
  • Human Resources Representative
  • Director of Training
  • Incident Response Team Leader
  • Others as identified…
  • Documents and other information that may be requested for investigations/reviews

a. Policies and Procedures and other evidence that addresses the following:

  • Prevention, detection, containment, and correction of security violations
  • Employee background checks and confidentiality agreements
  • Establishing user access for new and existing employees
  • List of authentication methods used to identify users authorized to access EPHI
  • List of individuals and contractors with access to EPHI to include copies of pertinent Business Associate agreements
  • List of software used to manage and control access to the Internet
  • Detecting, reporting, and responding to security incidents (if not in the security plan)
  • Physical security
  • Encryption and decryption of EPHI
  • Mechanisms to ensure the integrity of data during transmission – including portable media transmission (i.e. laptops, cell phones, blackberries, thumb drives)
  • Monitoring systems use – authorized and unauthorized
  • Use of wireless networks
  • Granting, approving, and monitoring systems access (for example, by level, role, and job function)
  • Sanctions for workforce members in violation of policies and procedures governing EPHI access or use
  • Termination of systems access
  • Session termination policies and procedures for inactive computer systems
  • Policies and procedures for emergency access to electronic information systems
  • Password management policies and procedures
  • Secure workstation use (documentation of specific guidelines for each class of workstation (i.e., on-site, laptop, and home system usage)
  • Disposal of media and devices containing EPHI

b. Other Documents:

  • Entity-wide Security Plan
  • Risk Analysis (most recent)
  • Risk Management Plan (addressing risks identified in the Risk Analysis)
  • Security violation monitoring reports
  • Vulnerability scanning plans
  • Results from the most recent vulnerability scan
  • Network penetration testing policy and procedure
  • Results from a most recent network penetration test
  • List of all user accounts with access to systems that store, transmit, or access EPHI (for active and terminated employees)
  • Configuration standards to include patch management for systems that store, transmit, or access EPHI (including workstations)
  • Encryption or equivalent measures implemented in systems that store, transmit, or access EPHI
  • Organization chart to include staff members responsible for general HIPAA compliance to include the protection of EPHI
  • Examples of training courses or communications delivered to staff members to ensure awareness and understanding of EPHI policies and procedures (security awareness training)
  • Policies and procedures governing the use of virus protection software
  • Data backup procedures
  • Disaster recovery plans
  • Disaster recovery tests plans and results
  • Analysis of information systems, applications, and data groups according to their criticality and sensitivity
  • Inventory of all information systems to include network diagrams listing hardware and software used to store, transmit or maintain EPHI
  • List of all Primary Domain Controllers (PDC) and servers
  • Inventory log recording the owner and movement media and devices that contain EPHI
  • Let us help you in completing your HIPAA compliance with an audit.

View HIPAA Security Policies and Procedures

The OCR Audit Process

The Office for Civil Rights has published the audit protocols for Privacy and Security. There is no longer any reason to delay establishing full compliance for Covered Entities and Business Associates. The recently issued Omnibus Rule clarifies that enforcement of HIPAA compliance standards has arrived and will be vigorously pursued. Penalties and fines will be forthcoming for those that put off establishing compliant operations, and now-published Privacy and Security Audit Protocols make equally clear what each entity can expect.

We have molded these protocols into our collaborative, consultative process. This ensures that we obtain all the required information but in a neither painful nor adversarial manner. Our goal is to gain the facts and insight to tailor changes to your work processes to bring them smoothly into compliant performance. The result is constructive changes and adjustments where and as needed with minimal disruption.

Our HIPAA Audit Process

OCR does not need to understand your environment: they need to confirm that you are doing all you are required to do, and find you if you aren’t. They have no interest in your operations beyond this determination and result. Other HIPAA Compliance Audit Service providers are likewise driven. Neither is concerned with the burden this can create, whether any efficiencies can be cogenerated, and achieving compliance to offset it. This is precisely where we are different from all the rest. We do care.

We understand the escalating costs you face, the mounting bureaucracy of regulations and paperwork, the increased drive to automate, and the disruptive change that can cause. Most HIPAA Compliance Audit Service providers grasp this without direct experience. We know the challenges you face because we have been there ourselves. That is why we work with and for you to achieve these goals: get you compliant and set it up to stay that way by building it into your processes.

Our techniques are the industry-standard, time-proven methods used by all firms:

  • Interview
  • Examination
  • Observation
  • Substantive Testing

We interview your in-house experts to determine their knowledge, awareness, and engagement with the importance of these requirements to gain a sense of the environment. We share with them our knowledge of the regulations to enhance their knowledge.

We examine your policy and guidance documentation to ensure that the regulatory requirements are adequately embodied in them. You have established the correct framework for performance, internal enforcement, and corrective action when needed.

We observe your staff at work as part of our gaining familiarity with your environment and to ensure that what we found in your documentation is being practiced by your workforce.

We substantively test various parts of your automated systems to ensure that the stated specifications to support privacy and achieve the requirements of the Security Rule are in place and functioning correctly.

Our process verifies that all the requirements are being met regularly and reliably so that your expectations are being met and so that you can be confident in knowing rather than trusting that things are working properly.

The process is the same for both Covered Entities and Business Associates. One standard for all appropriate to each operational context means the Covered Entity can be assured that their Business Associates are meeting the requirements just as they are, thus having greater peace of mind and greater risk control at all levels.

HIPAA compliance audits for covered entities and business associates are essential for maintaining patient data integrity and avoiding costly non-compliance issues. These audits offer numerous benefits, including risk mitigation, legal protection, cost savings, improved reputation, and process efficiency.

By following a systematic methodology, these audits help organizations identify and rectify areas of non-compliance, ensuring that HIPAA regulations are consistently upheld. In an era where data breaches and privacy concerns are rising, investing in HIPAA compliance audit services is not just a best practice; it’s a necessity for the healthcare industry.

Please contact us for more information on how our HIPAA Compliance Audit Services can help you to achieve and stay HIPAA compliant Bob@hipaatraining.net or call (515) 865-4591

USER RATING: HIPAA Audit Management Program is rated 4.8 out of 5 by 1503 users.