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Does your IT company provide full HIPAA Security Risk assessments and Audits?

You may not realise it but HIPAA law requires more than just Medical facilities to adhear to the HIPAA regulations.

The following are the types of company’s that are required by law to perform HIPAA audits.

  • Hospitals
  • Urgent Care Clinics
  • Dental Offices
  • Nursing Homes
  • Behavioral Health Facilities
  • Diagnostic Labs
  • Correctional Facilities
  • Pharmacies

However In addition to the above there are many other businesses that are exposed:

  • IT Service Providers
  • Shredding Companies
  •  Documents Storage Companies
  • Attorneys, Accountants
  • Collection Agencies
  • EMR companies
  • Data Centers
  • Online Backup companies
  • Cloud vendors
  • Insurance Agents
  • Revenue Cycle Management vendors
  • Contract Transcriptionists

The following are the reports we provide:

HIPAA Policies & Procedures. The Policy and Procedures are the best practices that we have formulated to comply with the technical requirements of the HIPAA Security Rule. The policies spell out what your organization will do while the procedures detail how you will do it. In the event of an audit, the first thing an auditor will inspect are the Policies and Procedures documentation. This is more than a suggested way of doing business. The Policies and Procedures have been carefully thought out and vetted, referencing specific code sections in the Security Rule and supported by the other reports we provide.

HIPAA Risk Analysis. HIPAA is a risk-based security framework and the production of a Risk Analysis is one of primary requirements of the HIPAA Security Rule's Administrative Safeguards. In fact, a Risk Analysis is the foundation for the entire security program. It identifies the locations of electronic Protected Health Information (ePHI,) vulnerabilities to the security of the data, threats that might act on the vulnerabilities, and estimates both the likelihood and the impact of a threat acting on a vulnerability. The Risk Analysis helps HIPAA Covered Entities and Business Associates identify the locations of their protected data, how the data moves within, and in and out of, the organization. It 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. The value of a Risk Analysis cannot be overstated. Every major data breach enforcement of HIPAA, some with penalties over $1 million, have cited the absence of, or an ineffective, Risk Analysis as the underlying cause of the data breach. The Risk Analysis must be run or updated at least annually, more often if anything significant changes that could affect ePHI.

HIPAA Risk Profile. A Risk Analysis should be done no less than once a year. However, Prestige Computer Solutions has created an abbreviated version of the Risk Analysis called the HIPAA Risk Profile designed to provide interim reporting in a streamlined manner. Whether performed monthly or quarterly, the Risk Profile updates the Risk Analysis and documents progress in addressing previously identified risks, and finds new ones that may have otherwise been missed and resulted in a data breach.

HIPAA Management Plan. Based on the findings in the Risk Analysis, the organization must create a Risk Management Plan with tasks required to minimize, avoid, or respond to risks. Beyond gathering information, Prestige Computer Solutions 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 Risk Management plan defines the strategies and tactics the organization will use to address its risks.

Evidence of HIPAA Compliance. Just performing HIPAA-compliant tasks is not enough. Audits and investigations require evidence that compliant tasks have been carried out and completed. Documentation must be kept for six years. The Evidence of Compliance includes log-in files, patch analysis, user & computer information, and other source material to support your compliance activities. When all is said and done, the proof to proper documentation is accessibility and the detail to satisfy an auditor or investigator is included in this report.

External Network Vulnerability Scan.. Detailed reports 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.

HIPAA On-Site Survey. The On-site Survey is an extensive list of questions about physical and technical security that cannot be gathered automatically. The survey includes questions ranging from how facility doors are locked, firewall information, how faxes are managed, and whether servers are on-site, in a data center, or in the Cloud.

Disk Encryption Report. 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.

File Scan Report. The underlying cause identified for many data breaches is that the organization did not know that protected data was stored on a device that was lost or stolen. After a breach of 4 million patient records a hospital executive said, "Based on our policies that data should not have been on those systems." The File Scan Report identifies data files stored on computers, servers, and storage devices. This report is useful to identify local data files that may not be protected. Based on this information the risk of a breach could be avoided if the data was moved to a more secure location, or mitigated by encrypting the device to protect the data and avoid a data breach investigation.

User Identification Worksheet. The User Identification Worksheet takes the list of users gathered by the Data Collector and lets you identify whether they are an employee or vendor. Users who should have been terminated and should have had their access terminated can also be identified. This is an effective tool to determine if unauthorized users have access to protected information. It also is a good indicator of the efforts the organization goes to so terminated employees and vendors have their access quickly disabled. 

Computer Identification Worksheet. The Computer Identification Worksheet lets you identify those that store or access ePHI. This is an effective tool in developing data management strategies including secure storage and encryption.

Network Share Identification Worksheet. The Network Share Identification Worksheet takes the list of network shares  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.

HIPAA Supporting Worksheets. A set of individual documents are provided to show detailed information and the raw data the backs up the Evidence of Compliance. These includes the various interviews and worksheets, as well as detailed data collections on shares and login analysis.

For more information on HIPAA and our HIPAA Services and reports please feel free to contact us