Documentation
- Risk Assessments need to be completed annually.
- All gaps have been remediated.
- Review your policy and procedures every year for business or legal changes.
- Document that all audit logs have been reviewed in the current year and gaps have been remediated.
- Document that all audit logs have been reviewed in the current year and gaps have been remediated.
- Keep track of visitors to your physical site.
- Keep track of storage devices (Hard Drives, USB Flash Drives) that have been properly destroyed.
- Log all viruses and malware attacks to The Guard’s Incident Manager.
- Confirm any new business associates have completed their technical audit and that you have a signed BAA.
Security
- Send quarterly security and procedure reminders to staff.
- Log out when leaving workstation, turn on alarm when leaving, etc.
- Update passwords to a minimum of eight (8) characters in length, using a special character and capital letter.
- Restrict sequential, repetitive characters, context specific passwords, and commonly used passwords (i.e. 12345, aaaaaa, the name of the site, p@ssw0rd, and dictionary words).
- Make sure you are not sharing passwords.
- Make sure you are not sharing passwords.
- Make sure you have encrypted email or a policy that no emails containing ePHI are to be sent. Restrict admin rights to any PHI software.
- Make sure your staff understands that breaches occur. If a breach occurs, please report it to the Privacy or Security Officer for resolution.
Training
- Make sure all employees (new and existing) have completed their new hire, or yearly HIPAA training.
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