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On March 21, 2016, the Office for Civil Rights announced their launch of Phase 2 of the HIPAA Audit Program for covered entities and business associates. As they announced, the 2016 Phase 2 HIPAA Audit Program will review the policies and procedures adopted and employed by covered entities and their business associates to meet selected standards and implementation specifications of the Privacy, Security, and Breach Notification Rules. The OCR has begun to obtain and verify contact information to identify covered entities and business associates of various types and determine which are appropriate to be included in potential auditee pools.
Per the OCR every covered entity and business associate is eligible for an audit. These include covered individual and organizational providers of health services; health plans of all sizes and functions; health care clearinghouses; and a range of business associates of these entities. For this phase of the audit program, OCR is identifying pools of covered entities and business associates that represent a wide range of health care providers, health plans, health care clearinghouses and business associates. By looking at a broad spectrum of audit candidates, they state they can better assess HIPAA compliance across the industry – factoring in size, types and operations of potential auditees. Their sampling criteria for auditee selection will include the size of the entity, affiliation with other healthcare organizations, the type of entity and its relationship to individuals, whether an organization is public or private, geographic factors, and present enforcement activity with OCR.
OCR plans to conduct desk and onsite audits for both covered entities and their business associates. The first set of audits will be desk audits of covered entities followed by a second round of desk audits of business associates. These audits will examine compliance with specific requirements of the Privacy, Security, or Breach Notification Rules and auditees will be notified of the subject(s) of their audit in a document request letter. All desk audits in this phase will be completed by the end of December 2016.
The third set of audits will be onsite and will examine a broader scope of requirements from the HIPAA Rules than desk audits. Some desk auditees may be subject to a subsequent onsite audit.
If an entity does not respond to requests for information from OCR, including address verification, the pre-screening audit questionnaire and the document request of those selected entities, OCR will use publically available information about the entity to create its audit pool. An entity that does not respond to OCR may still be selected for an audit or subject to a compliance review.
To read the full press release go to: OCR Press Release
Evolve's HIPAA Privacy and Security for Covered Entities and HIPAA Privacy and Security for Business Associates courses will ensure you meet your staff training requirements.