The Health Insurance Portability and Accountability Act (HIPAA) is a regulatory framework designed to safeguard patient health information, setting standards for data privacy and security. Ensuring your organization’s compliance with HIPAA is more than just a legal obligation—it’s a necessary step to provide responsible, ethical care. This Peak Post will guide you through the process of preparing for a HIPAA assessment, delineating each step in the process.

Understanding HIPAA Requirements

Before diving into the assessment process, you need a thorough understanding of the requirements set forth by HIPAA. This includes familiarizing yourself with the Privacy Rule, Security Rule, Breach Notification Rule, and Omnibus Rule. Moreover, you should understand the roles and responsibilities of covered entities and business associates as defined by HIPAA. This foundational knowledge will serve as your guide throughout your preparation process.

The Privacy Rule safeguards PHI, the Security Rule protects ePHI, the Breach Notification Rule mandates how breaches must be reported, and the Omnibus Rule addresses several miscellaneous provisions including enforcing the roles of business associates. Read the full text of these rules, often available on HHS’s website, or review summaries and guidance provided by trusted healthcare legal resources. Remember, understanding these rules is the first step towards HIPAA compliance.

Appointing a Privacy and Security Officer

A key part of your preparation will be designating individuals to oversee your organization’s HIPAA compliance. This individual, or individuals, will be responsible for developing, implementing, and enforcing your organization’s HIPAA policies and procedures. They should be well-versed in the requirements of HIPAA and capable of providing guidance to all staff. These roles could be filled by existing employees or by hiring new personnel. It’s crucial that these individuals are given the authority and resources to manage HIPAA compliance effectively.

Conducting a Risk Analysis

The next step is a comprehensive risk analysis—an examination of potential threats to the confidentiality, integrity, and availability of electronic protected health information (ePHI). A risk assessment is the foundation of your HIPAA assessment. This involves reviewing your organization’s systems, processes, and locations to identify where PHI is created, received, stored, and transmitted, followed by identifying and documenting potential vulnerabilities and threats to each of those areas. This helps to build a clear picture of areas of risk that need to be addressed. Consider physical risks such as unauthorized access to facilities or equipment, technical risks like inadequate firewalls or encryption, and administrative risks such as lack of employee training or weak policies. This process should be thorough, repeatable, and well-documented to form a baseline for your risk management efforts.

Developing a Risk Management Plan

Once your risk analysis is complete, develop a risk management plan to implement security measures to manage identified risks. This should detail how your organization plans to address the identified vulnerabilities, reducing them to reasonable and appropriate levels. This plan should include implementation specifications for each security measure adopted. This could include physical security measures (like improved locks or surveillance cameras), technical measures (like stronger passwords and encryption), and administrative measures (like enhanced training programs or policies). Your risk management plan should be a living document, constantly updated as your organization changes, new risks are identified, and existing ones evolve.

Training Your Employees

All staff members who handle PHI must be thoroughly trained on HIPAA regulations and your organization’s specific policies and procedures. Training should not be a one-time event. Regular, updated training that covers the basics of HIPAA, as well as your organization’s specific policies and procedures, is crucial. Training should include practical guidelines for handling and protecting PHI, managing potential breaches, and maintaining and understanding patient rights. Training should be conducted upon hiring, when changes are made to HIPAA or your policies, and periodically regardless of changes. Keep detailed records of who was trained, when, and on what topics. Remember, an informed workforce is one of the best defenses against HIPAA violations.

Develop, Review and Update Policies and Procedures

Based on your risk assessment, create and implement HIPAA-compliant policies and procedures. This includes but is not limited to developing guidelines for the proper use and disclosure of ePHI, how breaches are reported and mitigated, the processes for receiving and handling patient consent, ensuring workforce members receive adequate training, your protocol for addressing patient rights as outlined in the Privacy Rule, and implementing technical safeguards such as access controls, encryption, and secure data transmission. Policies and procedures should clearly articulate how your organization complies with each HIPAA rule. Regularly review these policies and procedures to ensure they remain current and reflect any changes in your organization or updates to the HIPAA regulations.

Organizing and Documenting

HIPAA requires that you maintain certain types of documentation for a minimum of six years. This includes your risk analysis, risk management plan, policies and procedures, employee training records, policies and procedures, business associate agreements, security audits, and more. Keeping all documents organized, easily retrievable, and stored securely will simplify your HIPAA assessment and demonstrate your commitment to compliance.

Implementing a Contingency Plan

Emergencies like natural disasters, power outages or cyber-attacks can pose a threat to the security of ePHI. Implement a contingency plan that outlines how your organization will protect ePHI during and after these unexpected events. This should include a data backup plan to create and maintain retrievable copies of ePHI, a disaster recovery plan to restore lost data and resume normal operations, and an emergency mode operation plan to protect and secure PHI during a crisis. Regular testing and revisions of the plan should be conducted to ensure its effectiveness.

Regular Auditing and Monitoring

To ensure ongoing compliance with HIPAA, conduct regular audits of your policies, procedures, and systems to identify any potential gaps in your organization’s compliance. Regular monitoring will help identify any non-compliance issues early, allowing you to address them promptly and avoid substantial fines. Regular security audits would also guide the organization in identifying areas of potential improvement in how it protects ePHI.

Addressing Third-Party Risks

If your organization works with third-party vendors or business associates that have access to or handle ePHI, they must also be HIPAA compliant. Such third-party business associates should sign a Business Associate Agreement (BAA), which formalizes their commitment to safeguarding PHI. It’s also advisable to conduct due diligence before signing BAAs to ensure these parties have robust privacy and security practices in place.

Preparing for Breaches

Despite best efforts, breaches can still occur. It’s important to have a breach response plan in place to ensure that any breaches of ePHI are quickly identified, addressed, and reported. This plan should include a clear process for notifying affected individuals, the Department of Health and Human Services (HHS), and, in cases of breaches affecting more than 500 individuals, the media.


Preparing for a HIPAA assessment may be a complex process, but it’s crucial to maintain the privacy and security of patient information. Following these steps will provide your organization with a solid foundation for HIPAA compliance and ready you for your HIPAA assessment. Remember, compliance is an ongoing process—regular review and updates are crucial. If you’re uncertain about any aspect of HIPAA compliance, do not hesitate to seek expert advice or legal consultation.

Please reach out if you would like to learn more about how Audit Peak can assist you with your HIPAA compliance or for a free consultation. WE WILL TAKE YOU TO THE PEAK.