Health Information Management

HIPAA Q&A: You’ve got questions. We’ve got answers!

HIM-HIPAA Insider, September 8, 2014

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Submit your HIPAA questions to Editor Jaclyn Fitzgerald at and we will work with our experts to provide you with the information you need.

Q: I work at a skilled nursing facility and I want to ensure that the organization is HIPAA compliant. What requirements and safeguards are necessary to ensure HIPAA compliance at our facility? Is there a document we can or should use to help us maintain compliance?
A: The best place to find out more about HIPAA privacy and security requirements is from OCR, which has published a wealth of information about HIPAA requirements, including guidance for small practices and health plans. OCR has also made available a sample business associate agreement and a model Notice of Privacy Practices.
To ensure your security program is up to date, you must conduct a risk analysis. A risk analysis is the foundation of any good security program and is mandated by the HIPAA Security Rule. A risk analysis should be conducted annually and when any major business or IT system change occurs. OCR and the Office of the National Coordinator for Health Information Technology has made available a risk analysis tool. You can conduct the risk analysis yourself or find a reputable vendor to assist you.
Editor’s note: Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, Oregon, answered this question for HCPro’s Briefings on HIPAA newsletter.

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