HIPAA Compliance Checklist for Computers and Computer Networks:
- HIPAA Policies and Procedures
- Develop and implement comprehensive HIPAA policies and procedures for your organization
- Ensure policies and procedures are regularly reviewed and updated
- Train employees on HIPAA requirements and your organization’s policies
- Risk Assessment and Management
- Conduct a thorough risk assessment to identify potential risks and vulnerabilities to the confidentiality, integrity, and availability of protected health information (PHI)
- Implement a risk management plan to address identified risks and vulnerabilities
- Regularly review and update the risk assessment and management plan
- Access Controls
- Implement unique user IDs and strong passwords for each employee accessing PHI
- Use two-factor authentication for added security
- Restrict access to PHI to only those employees who require it for their job functions
- Regularly review user access rights and modify as needed
- Data Encryption
- Encrypt PHI at rest (e.g., on hard drives, servers, and backup storage)
- Encrypt PHI in transit (e.g., over email and other communications)
- Use secure methods for transferring PHI, such as VPNs or secure file transfer protocols
- Security Software and Updates
- Install and maintain up-to-date antivirus and antimalware software on all devices that access PHI
- Regularly apply security patches and updates to operating systems, software, and firmware
- Utilize intrusion detection and prevention systems (IDS/IPS) to monitor for potential threats
- Network Security
- Implement a properly configured firewall to protect PHI from unauthorized access
- Secure wireless networks with strong encryption methods and access controls
- Regularly audit network security configurations and devices
- Physical Security
- Secure computers and servers containing PHI in locked rooms or cabinets
- Implement access controls for areas with sensitive equipment or information
- Use security cameras and alarm systems to monitor for unauthorized access
- Backup and Data Recovery
- Regularly back up PHI to a secure, offsite location
- Implement a data recovery plan to ensure PHI can be restored in case of loss or damage
- Test data recovery procedures to confirm their effectiveness
- Incident Response and Breach Notification
- Develop an incident response plan to address security incidents and breaches involving PHI
- Train employees on how to identify, report, and respond to potential security incidents
- Follow breach notification requirements outlined in the HIPAA Breach Notification Rule
- Business Associate Agreements
- Establish written agreements with business associates who handle PHI on your behalf
- Ensure business associates are aware of their HIPAA obligations and are compliant
- Regularly assess and monitor the compliance of your business associates
- Employee Training and Awareness
- Provide regular HIPAA training for all employees who access PHI
- Ensure employees understand the importance of protecting PHI and their responsibilities under HIPAA
- Create a culture of security awareness within the organization
- Audit and Compliance Monitoring
- Regularly audit your organization’s compliance with HIPAA requirements
- Address any identified issues or vulnerabilities in a timely manner
- Maintain documentation of your organization’s HIPAA compliance efforts
- Mobile Device Management
- Implement a mobile device management (MDM) policy for devices that access or store PHI
- Require password protection and encryption on all mobile devices
- Implement remote wipe capabilities for lost or stolen devices
- Regularly update and patch mobile devices to ensure security
- Secure Disposal and Destruction of PHI
- Develop and implement policies for the secure disposal and destruction of electronic PHI (ePHI) and hardware storing ePHI
- Use secure methods for data deletion, such as overwriting, degaussing, or physical destruction of hardware
- Maintain records of disposal and destruction activities
- Logging and Monitoring
- Enable logging and monitoring features on all devices and systems that access, store, or transmit PHI
- Regularly review logs for suspicious activities or security incidents
- Retain logs in accordance with your organization’s retention policy and applicable regulations
- Contingency Planning
- Develop a contingency plan to ensure the continued availability of PHI in case of emergencies or disasters
- Include data backup, disaster recovery, and emergency mode operation plans
- Test and update contingency plans regularly
- Technical Safeguards
- Implement transmission security measures to guard against unauthorized access to PHI during transmission
- Utilize network segmentation to isolate sensitive systems and data
- Use data loss prevention (DLP) tools to prevent unauthorized transfer or leakage of PHI
- Facility Access Controls
- Develop and implement policies for controlling physical access to facilities that store, process, or transmit PHI
- Maintain visitor access logs and require visitor identification
- Implement additional security measures, such as key card access or biometric authentication
- Security Management Process
- Designate a security officer responsible for overseeing and managing HIPAA compliance efforts
- Implement a security management process that includes regular risk assessments, policy development, and employee training
- Documentation and Record Retention
- Maintain comprehensive documentation of all HIPAA-related policies, procedures, and activities
- Retain records in accordance with the HIPAA Privacy Rule (generally six years)
- Ensure documentation is readily available for audits or inspections
By addressing all of the items on this HIPAA compliance checklist, your organization will be better prepared to protect the privacy and security of PHI, comply with regulatory requirements, and minimize the risk of breaches and penalties.
