What is HIPAA Compliance Assessment

Keep your ePHI secure with HIPAA compliance assessments. Find out when they’re essential and how HIPAA Vitals can help.‍

HIPAA Security requires covered entities and business associates to perform periodic technical and non-technical evaluations in response to environmental or operational changes affecting the security of ePHI. Evaluation establishes the extent to which an entity’s security policies and procedures meet the requirements of the Security Rule.  

Thus, the HIPAA compliance assessment (or evaluation) is a structured evaluation of an organization's adherence to the HIPAA rules and requirements. This assessment typically includes a thorough review of HIPAA administrative, physical, and technical safeguards. This helps go through all policies and procedures the organization has or lacks, as well as identifying potential threats to PHI.  

The HIPAA compliance assessment includes three main components: initial evaluation, continuing evaluation, and periodic evaluation.  

Initial assessment

The initial assessment involves reviewing policies, procedures, and technological safeguards the organization already has to satisfy the HIPAA Security Rule requirements. Hence, by conducting a thorough review of operations and assessing areas responsible for maintaining implemented safeguards, organizations may evaluate their compliance and create a baseline for future evaluations.

Continuing assessment

The continuing assessment is a systematic review of changes that affect ePHI security at any event that may affect the security of sensitive healthcare data and systems. Data breaches, adoption of new technologies, and organizational structural changes are a few examples of trigger events that require HIPAA compliance assessment. These may include any technical (hardware, software, media), environmental (physical location, facilities), or operational (people, processes) changes that might affect the security of ePHI.  

Periodic assessment

The periodic assessment ensures that any changes in the organizational environment since the last evaluation do not compromise HIPAA compliance. Periodic evaluations are also necessary to check whether the existing security measures are strong enough to ensure the confidentiality, availability, and integrity of ePHI. The changes that may occur within the organization may be technical and non-technical as they relate to technological and physical environments as well as business operations. As we already mentioned, the periodic evaluation utilizes the baseline information and evaluates all changes that may have affected the organization's security.

When to Carry out a HIPAA Compliance Assessment

HIPAA compliance assessments are essential for ensuring your ePHI is stored and transmitted securely. Here are the key scenarios when an assessment is necessary:  

‍Annually. Try conducting annual HIPAA compliance assessments to identify and address compliance gaps.  

‍Before a formal HIPAA audit. If your organization is preparing for a HIPAA audit by HHS OCR or another regulatory body, a proactive compliance assessment helps identify and resolve compliance gaps before official auditors find them. This would help save your money and reputation, as non-compliance and data breaches are always more burdensome.  

‍After a security incident or data breach. If your organization experiences a healthcare data breach, ransomware attack, or unauthorized access, a compliance assessment helps pinpoint weaknesses and implement corrective actions.  

‍Before adopting new technologies or services. Whether migrating to the cloud, implementing AI solutions, or using third-party vendors, a HIPAA compliance evaluation ensures that new solutions comply with the HIPAA Security Rule.  

‍Following organizational changes. Expanding operations, merging with another entity, or restructuring IT infrastructure can introduce compliance gaps that must be addressed.  

‍When required by business associates or regulators. Some insurance providers, business partners, or regulatory bodies may request proof of HIPAA compliance before working with your organization.  

By conducting regular assessments, organizations can identify risks, strengthen security controls, and avoid costly penalties, ensuring the protection of patient data and maintaining compliance. Evaluation of all the environmental or operational changes provides the covered entity with a good chance to reduce the associated risks to reasonable levels as well as confirm their HIPAA compliance efforts.

Difference Between HIPAA Compliance Assessment and HIPAA Risk Assessment

A HIPAA compliance assessment evaluates an organization’s overall adherence to HIPAA regulations, ensuring that administrative, physical, and technical safeguards are properly implemented. It involves reviewing policies, procedures, employee training, and documentation to identify compliance gaps. Typically conducted as part of an ongoing compliance program, this assessment provides a broad compliance status report, helping organizations align with regulatory requirements.  

A HIPAA risk assessment, on the other hand, focuses on identifying and analyzing potential threats to Protected Health Information (PHI). It examines specific vulnerabilities in IT systems, workflows, and security measures that could lead to data breaches or non-compliance. Unlike a compliance assessment, a risk assessment is a required HIPAA activity that must be conducted periodically and whenever significant changes occur in an organization’s infrastructure or security landscape. The outcome is a detailed risk analysis that helps businesses prioritize and mitigate threats to PHI.

The importance of HIPAA compliance assessment

HIPAA compliance assessment helps HIPAA-covered entities and business associates identify gaps in their security, privacy, and breach notification policies to ensure ePHI security. Particularly, the main benefits of the HIPAA compliance assessment include:

• identifying compliance gaps
• reducing data security risks
• reducing finanical and legal liabilities
• and building trust with partners

First, HIPAA compliance assessment helps businesses identify gaps in their current policies and practices, ensuring that they are fully aligned with HIPAA regulations to avoid costly penalties. Second, as healthcare organizations are often targets for cyberattacks and data breaches, a compliance assessment identifies potential security weaknesses, allowing businesses to take proactive steps to safeguard ePHI. Third, non-compliance can lead to significant fines and legal issues. By conducting a compliance assessment, HIPAA-covered entities can minimize the risk of violations, avoiding financial losses and potential legal consequences.

Finally, by demonstrating your commitment to HIPAA compliance, businesses can easily build trust with clients, patients, and business partners by demonstrating a commitment to safeguarding sensitive health data and maintaining high standards of privacy and security.

Common Challenges in HIPAA Compliance Assessment

Organizations often face several obstacles when conducting HIPAA compliance assessments, including:  

‍Lack of internal expertise. Many businesses, especially small and medium-sized ones, lack dedicated compliance professionals, making it difficult to interpret and implement HIPAA requirements effectively.  

‍Changing regulatory requirements. HIPAA rules and enforcement evolve over time, requiring organizations to stay updated and continuously adjust their policies and procedures.  

‍Gaps in third-party vendor compliance. Business associates handling protected health information (PHI) must also comply with HIPAA, yet organizations often struggle to assess and monitor their vendors' security practices.  

Overcoming HIPAA compliance challenges starts with the right support and tools. Partnering with HIPAA compliance consultants provides expert guidance, ensuring organizations correctly interpret and apply regulations. Automated assessments and compliance tools—like Planet 9 Security’s HIPAA Vitals—help HIPAA-covered organizations to streamline the process by identifying gaps, offering clear recommendations, and simplifying documentation.  

HIPAA Vitals: Planet 9’s Free HIPAA Compliance Assessment Solution

Planet 9 developed - HIPAA Vitals - to help organizations with their compliance evaluation efforts. Besides compliance evaluation, HIPAA Vitals also helps to cope with ePHI security issues related to policies, procedures, and controls. Being based on such reputable sources as OCR Audit Protocol, NIST 800-66, and HIPAA Security Series, as well as years of expertise and experience of our professionals, HIPAA Vitals is an effective tool for maintaining HIPAA compliance.  

How to use the solution?  

Using HIPAA Vitals is as simple as taking a guided compliance journey—answer, assess, and act with confidence:

• Create an account
• Set up your company profile.
• Complete the HIPAA Assessment. You'll answer a detailed questionnaire covering administrative, physical, and technical safeguards, along with policies, procedures, and organizational requirements—all aligned with HIPAA standards. Each question includes clear prompts and references to guide your responses.
• Review compliance gaps and recommendations. Get a detailed analysis of your organization's compliance status and actionable steps to address any deficiencies.
• Remediate the compliance gap and enjoy the benefits of your HIPAA compliance!

Planet 9 HIPAA Compliance Assessment Services

Ensuring compliance with HIPAA involves a comprehensive approach that extends to regular risk assessments, employee training, and awareness programs, and developing thorough policies and procedures to manage and respond to security incidents effectively.  

‍Planet 9 HIPAA-compliance services offer a comprehensive approach to ensuring and maintaining HIPAA compliance and include:

• Conducting a discovery to understand the client’s organization, business processes, and technologies.
• Performing a HIPAA evaluation to identify safeguards in place and compliance gaps.
• Performing a risk assessment to identify risks to PHI.
• Developing a roadmap for addressing the identified compliance gaps and risks
• Assisting the client in executing the roadmap.

Schedule a free consultation today to explore how Planet 9 can help you achieve your security and compliance goals.