A Guide to Auditing and Monitoring HIPAA Privacy Compliance

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Price: $285 (Includes CD-ROM with documents and tools) Pages: 214 ISBN: 1-931467-54-4 © 2003 Pub Code: GHAM

April 14, 2003 – the deadline for HIPAA privacy compliance – has come and gone. But compliance with HIPAA privacy is a permanent process, not a test that covered entities either passed or failed on April 14. Installing effective HIPAA auditing and monitoring systems is the best way to avoid potentially massive fines, penalties, private lawsuits, and public relations nightmares.

A Guide to Auditing and Monitoring HIPAA Privacy Compliance will help you put into place effective systems that track your compliance efforts, by providing the tools you need to document your compliance, remedy deficiencies, and limit future liabilities.

HHS has maintained that its investigators are likely to look favorably upon covered entities that show a good-faith effort to comply with HIPAA privacy regulations. Use the tools and templates included in this valuable book (and on a companion CD-ROM) to audit and monitor all aspects of your HIPAA privacy program – and defend against compliance lapses.

This practical resource:

• Spells out the steps involved in monitoring a HIPAA privacy program, using a Monitoring Matrix and Question & Answer Monitoring Form to facilitate the monitoring process.
• Lists the top ten things to think about and not to miss when auditing and monitoring your HIPAA privacy program.
• Offers examples of how to audit specific requirements of the Privacy Rule, and raises a red flag on other parts of the privacy regulations that may pose compliance risks.
• Explains risk assessment methodologies, and provides sample tools for evaluating HIPAA privacy risks.

• About the Privacy Rule
• The Role of Auditing and Monitoring in Privacy Compliance

• Internal Control
• Risk Management

• Monitoring Controls & Categories

• Risk Assessment

• Planning the Audit
• Data Collection and Analysis (Performance Tests)
• Reports of Findings and Recommendations
• Audit Planning and Testing Template
• Outcome of Monitoring and Auditing
• Monitoring Regulatory Changes and Change Management

• Monitoring Matrix

• The Seven Steps for Audit Planning and Testing
• Adapting the Template to HIPAA Privacy

• Administrative Requirements
• General Uses and Disclosures for TPO
• Authorizations
• Notice of Privacy Practices
• Individual Rights

• Risk Assessment Matrix
• Risk Quantification Worksheet
• Risk Exposure Matrix
• Monitoring Matrix
• Q&A Monitoring Form
• Sampling Plan
• Audit Planning and Testing Template
• Audit Report

• Glossary
• References
• Web Links

Written By

JOY QUILL (Vice President, SMSInc) has been a private-sector consultant for more than seven years, following nearly 30 years in the federal sector, where she was a Regional Inspector General of HHS. Her specialties include conducting evaluations and assessments of Medicare and Medicaid issues and developing training programs for hospital systems, other health care entities, and government agencies. Ms. Quill routinely leads teams in the evaluation of compliance programs and implementation of training programs, including reviews of compliance with Corporate Integrity Agreements.

CORNELIA M. DORFSCHMID, Ph.D. MSIS, PMP (Senior Vice President & CIO, SMSInc) oversees SMSInc's technology efforts and directs all of the firm's systems, surveys, applications development, interactive CBT based training, and knowledge functions. She oversees the Compliance Interactive Tutorial System™ (CITS), a Web-based training tool for the American Medical Association; and HIPAA BASICS™, a Web-based HIPAA gap analysis, project planning, and monitoring tool (www.hipaabasics.net) that is widely used commercially and in the government sector. Dr. Dorfschmid is the author of the chapter on "Completing a Risk Assessment" in AIS's HIPAA Patient Privacy Compliance Guide.

Written For

• Privacy officers
• Compliance officers
• Intrernal auditors
• Risk managers
• IT managers
• Medical records directors
• Nursing managers
• Consultants
• Lawyers
• Other members of HIPAA compliance teams

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