HIPAA program Audit Checklist

       ☐ Identify the HIPAA rules (there are 3 rules)

       ☒ Security Rule

              – Mandatory for all organizations handling Electronic Protected Health Information (ePHI)

       ☐ Privacy Rule (If answered yes to any of these questions)

              – Are you a covered entity?

              – Are you a health care provider?

              – Are you a health plan or clearinghouse?

       ☐ Breach Notification Rule (If answered yes to any of these questions)

       – Are you a covered entity?

       – Are you a health care provider?

       – Are you a health plan or clearinghouse?

       ☐ Have you specified and properly documented the activities and procedures that make up your company’s control environment?

       ☐ Do you review documents on a regular basis to make sure they are up to date and accurate?

       ☐ Do you retain documents for at least six (6) years?

☐ Identify your current control environment posture

       ☐ What is the organization’s governance structure?

       ☐ What is the tone and example of executive leadership and management?

       ☐ Have you designed and implemented hiring and exit procedures?

       ☐ How are personnel who are implementing or directing internal controls evaluated for competency?

       ☐ Are possible threats being identified?

       ☐ Have you put any mitigating plans in place?

       ☐ Do you have a protocol for dealing with incidents and a disaster recovery plan in place?

       ☐ What kind of management supervision and governance do you have in place for your control the environment and reporting events, security problems, and fraud?

       ☐ Do you have a Business Associates Agreement (BAA) template for contact with all your vendors and subcontractors?

☐ Identify your current security environment posture

       ☐ Do you have access limited to positions that need it, with the appropriateness of the access being reviewed on a regular basis?

       ☐ Do you have policies in place for giving and taking away access from workers, customers, and other parties?

       ☐ Do you encrypt data while it’s in transit and while it’s at rest?

       ☐ Do you impose restrictions on administrative access to the technological stack?

☐ Identify your current risk mitigation environment posture

       ☐ Have you conducted vulnerability assessments or penetration testing on a regular basis to detect weaknesses in your environment?

       ☐ Do you have backup processes in place?

       ☐ Do you test your disaster recovery procedures on a yearly basis to guarantee that you can restart  operations in case of a calamity?

       ☐ Do you regularly check for intrusion attempts, system performance, and availability?

☐ Identify your current system changes and posture

       ☐ Are system modifications tested and authorized before they are implemented?

       ☐ Do you inform your employees about system changes?

       ☐ Are your controls being monitored on a regular basis?

       ☐ Have you enabled notification of settings changes?

       ☐ Is your technology up to date in terms of upgrades?

       ☐ Do you have a system in place for separating development and production tasks?

☐ Identify your current posture in a remote working environment.

       ☐ Is technology being used uniformly across all employee locations?

       ☐ Do you provide staff with regular security awareness training, address data privacy in common spaces, use secure connections while working from home, and raise awareness of phishing attempts?

       ☐ Do you use multifactor authentication to get into your company’s network and other systems?

       ☐ Have you deployed mobile device management to make sure that mobile devices are encrypted and authenticated?

☐ Implement controls to address your gaps

☐ Test the controls to ensure that they are operating effectively.

☐ Initiate kickoff to set expectations

☐ Grant them access to TrustCloud.