How should a HIPAA entity prepare for an official audit or review?

by | Mar 30, 2023 | HIPAA News and Advice

To effectively prepare for an official HIPAA audit or review, a HIPAA entity should comprehensively assess its policies, procedures, and documentation related to PHI, ensuring they align with HIPAA regulations, conduct internal mock audits to identify potential vulnerabilities, address any identified deficiencies by implementing corrective actions and staff training, maintain meticulous records of these actions, and establish clear lines of communication with the audit team while designating a point person to coordinate all audit-related activities, thereby demonstrating a proactive commitment to compliance and the safeguarding of PHI.

Preparation StepsDescription
Policy and Procedure ReviewAssess existing policies and procedures related to PHI for alignment with HIPAA regulations.
Verify coverage of permissible uses, security safeguards, breach response, and notifications.
Documentation EvaluationScrutinize documentation practices for accuracy, completeness, and accessibility.
Organize records such as risk assessments, security incident reports, and training programs.
Internal Mock AuditsConduct simulated audits to identify vulnerabilities and non-compliance areas.
Address deficiencies found during the mock audits.
Corrective Action ImplementationPromptly address deficiencies identified during mock audits.
Develop specific corrective actions to rectify compliance gaps.
Staff TrainingProvide regular training covering PHI handling, data breach response, and EHR system usage.
Tailor training to roles within the organization.
Meticulous Record-KeepingMaintain organized records of compliance efforts, corrective actions, and training activities.
Document the commitment to PHI security.
Designated Audit CoordinatorAppoint a point person or team to coordinate audit-related activities and communication with the audit team.
Ensure smooth interaction with auditors.
Communication with Audit TeamEstablish clear communication lines with the audit team to foster transparency and collaboration.
Respond promptly to inquiries and provide requested documentation.
Regulatory Compliance ReviewEnsure full compliance with the HIPAA Privacy Rule, Security Rule, and Breach Notification Rule.
Address gaps in alignment with regulations.
Privacy and Security AssessmentsRegularly conduct assessments to identify potential PHI handling risks and vulnerabilities.
Enhance security measures based on findings.
Breach Response Plan ReviewReview and update the breach response plan to meet current regulations and best practices.
Test the response plan’s effectiveness through simulations.
Continuous Improvement CommitmentDemonstrate proactive commitment to ongoing improvement in PHI security and compliance.
Update policies and procedures based on changing standards.
Third-Party Vendor ReviewAssess business associates’ compliance status and vendor handling of PHI.
Verify up-to-date business associate agreements.
Evidence Gathering PreparationPrepare documentation showing compliance efforts, corrective actions, and ongoing PHI security commitment.
Organize evidence for easy presentation.
Physical Security AssessmentEvaluate physical security measures in facilities where PHI is stored or accessed.
Ensure adequate access controls and safeguards.
Table: Steps in Preparing for a HIPAA Audit

The first step in preparing for a HIPAA audit involves a detailed review of the organization’s existing policies and procedures related to PHI. This review should encompass all aspects of PHI management, from its creation and storage to its transmission and disposal. Policies must be evaluated against the standards set forth by the HIPAA Privacy Rule, Security Rule, and Breach Notification Rule, ensuring that they align with the regulatory requirements and adequately address the organization’s unique operational environment. This includes verifying that the policies outline permissible uses and disclosures of PHI, detail security measures to protect against unauthorized access and establish protocols for breach response and notification. Healthcare entities should conduct a comprehensive assessment of their documentation practices. This entails scrutinizing the accuracy, completeness, and accessibility of records that pertain to PHI. Documentation not only serves as evidence of compliance but also demonstrates due diligence in the event of an audit. Organizations should maintain records of risk assessments, security incident reports, training programs, business associate agreements, and any other pertinent documents. These records should be organized in a manner that facilitates their retrieval and review by audit teams.

Recognizing the importance of proactive readiness, healthcare entities should initiate internal mock audits. These audits simulate the conditions of an official regulatory review, helping organizations identify potential vulnerabilities and areas of non-compliance. The mock audit process involves a systematic examination of policies, procedures, documentation, and security measures. By critically assessing their own practices, organizations can rectify deficiencies before they are flagged during an actual audit. Mock audits also enable organizations to fine-tune their communication and collaboration between departments, ensuring a unified response to audit-related inquiries. Upon identifying areas requiring improvement during mock audits, healthcare entities must promptly implement corrective actions. These actions should be specific, actionable, and designed to rectify the identified deficiencies. For instance, if the audit reveals gaps in workforce training related to PHI security, organizations should develop and deliver targeted training programs. If vulnerabilities are identified in the physical security of facilities where PHI is stored, appropriate measures must be instituted to address these concerns. The goal is to demonstrate a proactive approach to compliance and a commitment to continual improvement.

Staff training is important to effective audit preparation. Well-informed and educated employees are the front line of defense against potential HIPAA violations. Healthcare entities should conduct regular training sessions that cover topics such as PHI handling, data breach response, password management, and the appropriate use of electronic health records (EHR) systems. Training programs should be tailored to the roles and responsibilities of different personnel, ensuring that each member of the workforce is equipped with the knowledge and skills necessary to uphold the organization’s PHI security standards.

Throughout the audit preparation process, healthcare entities must maintain meticulous records of all actions taken. These records serve as a comprehensive trail of compliance efforts and can substantiate the organization’s commitment to PHI security. Audit teams will scrutinize these records to assess the organization’s diligence and responsiveness to identified deficiencies. Clear, well-organized documentation also helps audit teams navigate the complexity of the organization’s operations and facilitates a smoother review process. It is also prudent to establish clear lines of communication with the audit team. Designating a point person or team responsible for coordinating all audit-related activities streamlines communication and ensures a consistent and accurate flow of information. This designated individual can liaise with the audit team, addressing inquiries, providing documentation, and facilitating on-site visits, if necessary. This proactive approach demonstrates the organization’s commitment to transparency and collaboration, thereby fostering a positive rapport with the audit team.


Preparing for an official HIPAA audit requires an approach that encompasses policy review, documentation assessment, internal mock audits, corrective actions, staff training, and clear communication with audit teams. By meticulously evaluating policies and procedures, identifying vulnerabilities through mock audits, implementing corrective actions, conducting comprehensive training, and maintaining well-documented records, healthcare entities can position themselves for a successful audit outcome. This diligent and proactive preparation not only showcases compliance but also underscores the organization’s dedication to upholding patient privacy and PHI security in accordance with HIPAA regulations.

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