The HIPAA Security Rule Auditor Checklist gives you a high-level overview of how well the organization complies with the HIPAA provisions. The checklist details specific compliance items, their status, and helpful references. Use the checklist to quickly identify potential issues to be remediated in order to achieve compliance.
One of the first requirements is to have a set of policies and procedures used to implement ePHI data security and compliance with HIPAA. Some organizations don’t have a set of data protection policies – or at least one that conforms to HIPAA provisions. The tool provides an “out of the box” version of policies and procedures for HIPAA for use by those organizations.
Based on the findings in the HIPAA Compliance Assessment, the organization must create a HIPAA Management Plan with tasks required to minimize, avoid, or respond to risks. Beyond gathering information, Compliance Manager for HIPAA provides a risk scoring matrix that an organization can use to prioritize risks and appropriately allocate money and resources and ensure that issues identified are issues solved. The HIPAA Management Plan defines the strategies and tactics the organization will use to address its risks.
The HIPAA Risk Analysis is the foundation for the entire HIPAA compliance and IT security program. The HIPAA Risk Analysis identifies what protections are in place and where there is a need for more. The Risk Analysis results in a list of items that must be remediated to ensure the security and confidentiality of ePHI at rest and/or during its transmission.
This worksheet allows you to document business justifications for all of the allowed external ports, the protocol configured to use a specific port, and the documentation of any insecure configurations implemented and in use for a given protocol.
The Computer Identification Worksheet is used to augment the asset data that was collected during the internal network scan. Details include the Device Name, Device Type, IP Address, Operating System, System Description, as well as device and sensitive information classification. The ePHI Access Classification is used to determine the risk to the organization in the event of a security incident where the asset’s information is compromised.
The HIPAA Policy and Procedures Verification Worksheet will collect information about the network and environment that cannot be discovered through automated scans. This includes information principles relating to processing of ePHI, including sanctions, incident response, and Business Associates of the Covered Entity.
Assess the physical security and the workplace environment as it relates to information security. The worksheet will guide you through your assessment of the physical security. This worksheet includes information about the Information Security Officer. It is best done on-site as it requires identifying risk that may currently exist in the client’s environment outside the computer network itself.
Understanding where you have ePHI Data is an important component of HIPAA compliance. The Personal Data Scan System Selection Worksheet allows you to specify which systems are scanned for ePHI during the assessment process. A comprehensive scan should be performed annually to help identify and document all potential locations for personal data as defined by HIPAA.
During the ePHI scan performed by Compliance Manager for HIPAA, suspected ePHI may be detected in files stored on network and stand-alone computers. The ePHI Validation Worksheet report presents a record of which computer files were verified by a participant in the HIPAA assessment process as containing actual instances of ePHI.
Detailed report showing security holes and warnings, informational items including CVSS scores as scanned from outside the target network. External vulnerabilities could allow a malicious attacker access to the internal network.
Encryption is such an effective tool used to protect data that if an encrypted device is lost then it does not have to be reported as a data breach. The Disk Encryption Report identifies each drive and volume across the network, whether it is fixed or removable, and if Encryption is active.
The Network Share Identification Worksheet takes the list of network shares gathered by the Data Collection process and lets you identify those that store or access ePHI. This is an effective tool in developing data management strategies including secure storage and encryption.
Use the generated PowerPoint presentation as a basis for conducting a meeting presenting your findings from the Compliance Manager for HIPAA assessment process. General summary information along with the risk and issue score are presented along with specific issue recommendations and next steps.
It allows you to document explanations on suspect items. Your explanation can include why various discovered items are not true issues and indicate possible false positives. Additionally, you can explain why a certain compliance requirement should not apply to you – or an alternative way in which you have met the requirement.