Each year, behavioral health professionals are required to conduct six HIPAA audits. These audits assess your current HIPAA Privacy, Security, and Breach Notification practices against HIPAA standards. TBHI’s also previously discussed 8 Common HIPAA Violations That Increase Legal Risk. More details are discussed on HIPAA audit requirements.
Which HIPAA Audit is Required from Behavioral Health Providers?
As covered entities under HIPAA, behavioral health providers are required to conduct six annual HIPAA audits.
The required HIPAA audits include:
- Privacy Standards
- Security Rule Standards
- Security IT Risk Assessment
- Physical Site
- Asset and Device
- HITECH Subtitle D
What Does Each HIPAA Audit Require?
Each HIPAA audit has requirements based on a specific component of the HIPAA regulations.
Privacy Rule Audits:
- Privacy Standards. This audit requires behavioral health providers to implement policies and procedures to protect health information and train workforce members on these policies.
Security Rule Audits:
- Security Rule Standards. This audit requires behavioral health providers to implement policies and procedures that comply with the Security Rule. It also requires organizations to review these each year or an operational or environmental change within the organization. Lastly, workforce members must receive security awareness training.
- Security IT Risk Assessment. This HIPAA audit requires a security risk analysis to be conducted annually.
- Physical Site. This audit requires behavioral health providers to implement policies and procedures to limit physical access to electronic devices and review and modify security measures as needed.
- Asset and Device. This audit requires behavioral health providers to implement policies and procedures related to the security protection of electronic media and update security measures as needed.
Breach Notification Rules Audits:
- HITECH Subtitle D. This HIPAA audit requires organizations to implement policies and procedures related to breach notification and require workforce training on these policies.
Physical Site Audits and Home Offices
Even as a telehealth provider working from a home office, a Physical Site audit is still required. This is because your home office likely contains some protected health information, and this information must be protected from unauthorized disclosure or access. Unauthorized disclosure or access to PHI is considered a breach under the HIPAA regulation and can occur from incidental access, such as by a family member or friend stumbling upon patient records.
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