HIPAA Security Risk Assessment

HIPAA Security Risk Assessments for Behavioral Health Specialists


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HIPAA security risk assessments are an essential part of maintaining HIPAA compliance in your behavioral health practice.

HIPAA security risk assessments are an annual HIPAA requirement that all HIPAA-beholden health care providers must perform. Because of changes that your practice goes through over the course of the year, the federal government requires that you track and monitor these changes through security risk assessments to mitigate the risk of a security incident and related data breach.

But what does a HIPAA security risk assessment require from behavioral health professionals?

What Does a Security Risk Assessment Entail?

HIPAA security risk assessments require health care organizations to conduct targeted audits of the security measures they have in place. These measures include network protections and safeguards over your data.

HIPAA compliance sets national standards for the security, privacy, and integrity of health care data, called protected health information (PHI). PHI is any demographic data collected over the course of treatment that can be used to identify a patient. Common examples of PHI include names, addresses, telephone numbers, social security numbers, financial information, and health care records, to name a few.

The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) gives health care providers an online tool to perform their security risk assessments for free, which can be conducted by anyone at your practice or organization. HIPAA compliance requires that you maintain documentation of your compliance efforts, so be sure to retain your annual HIPAA security risk assessments.

Why a Security Risk Assessment isn’t Enough…

A security risk assessment is only a fraction of the federally mandated requirements to become HIPAA compliant. Below, we’ve listed a brief summary of how to become HIPAA compliant and what you need to be sure to address in order to protect your behavioral health organization from thousands of dollars in federal fines.

An effective HIPAA compliance program must address:

  • Self-Audits – HIPAA requires you to conduct annual audits of your practice to assess Administrative, Technical, and Physical gaps in compliance with HIPAA Privacy and Security standards.
  • Remediation Plans – Once you’ve identified gaps, you must implement remediation plans to reverse any potential HIPAA violations.
  • Policies, Procedures, Employee Training – To avoid HIPAA violations in the future, you’ll need to develop Policies and Procedures corresponding to HIPAA regulatory standards. Annual staff training on these Policies and Procedures is also required.
  • Documentation – Your practice must document efforts you take to become HIPAA compliant. This documentation is critical during a HIPAA investigation with HHS.
  • Business Associate Management – You must document all vendors with whom you share PHI, and execute Business Associate Agreements to ensure PHI is handled securely and mitigate liability.

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