HIPAA compliance is an ongoing responsibility for healthcare organizations and the businesses that support them. Protecting protected health information (PHI) requires more than having a privacy policy or asking employees to complete training once a year. Organizations need to understand where their risks are, put appropriate safeguards in place, and continually manage those risks.
Unfortunately, many HIPAA violations result from preventable errors. A missed risk analysis, poorly trained employee, outdated business associate agreement, or weak security practice can expose sensitive information and create serious compliance problems.
Understanding HIPAA common mistakes can help covered entities and business associates identify weaknesses before they result in a breach or regulatory investigation. Here are some of the most frequent problems organizations should watch for and how a strong HIPAA risk management program can help prevent them.
1. Failing to Conduct a Thorough HIPAA Risk Analysis
One of the most significant HIPAA common mistakes is failing to conduct and document an appropriate risk analysis.
A HIPAA risk analysis is designed to identify potential risks and vulnerabilities affecting PHI. Organizations should consider where PHI is created, received, maintained, and transmitted and evaluate the safeguards protecting that information.
This process should not be treated as a one-time compliance project. Technology changes. Employees come and go. Vendors change. New threats emerge. Organizations may also open new locations or implement new systems that introduce different risks.
Once risks have been identified, they need to be addressed through an organized HIPAA risk management plan. The HIPAA E-Tool® provides an interactive Risk Analysis and Risk Management module designed to help organizations identify risks, assign action steps and deadlines, and document their progress.
2. Inadequate Employee HIPAA Training
Employees can be one of an organization’s strongest defenses against HIPAA violations, but only when they understand their responsibilities.
Workforce members who handle PHI need appropriate training on HIPAA requirements and the policies and procedures that apply to their roles. Cybersecurity awareness is also increasingly important because phishing, credential theft, ransomware, and other attacks can begin with a simple employee mistake.
Training should address practical situations employees may encounter, such as recognizing suspicious emails, properly handling patient information, securely disposing of documents, and reporting potential privacy or security incidents.
Organizations should also document their training efforts. Being able to demonstrate who received training and when can become important during an audit or investigation.
3. Improperly Sharing Patient Information
Unauthorized or inappropriate disclosure of PHI is another common source of HIPAA violations.
These incidents do not always involve sophisticated cyberattacks. Something as simple as discussing patient information where others can hear it, sending information to the wrong recipient, or leaving paperwork where unauthorized individuals can see it may create a privacy problem.
Organizations should establish clear policies for how PHI is accessed, used, discussed, transmitted, and stored — including guidance on communicating with a patient’s family and friends.
Employees should understand that protecting patient information applies whether the information is electronic, printed, spoken, or otherwise communicated.
4. Weak Password and Access Controls
Not everyone within an organization needs access to every piece of patient information.
Organizations should evaluate who has access to PHI and whether that access is appropriate for each person’s responsibilities. Accounts belonging to former employees should be disabled promptly, and access privileges should be reviewed when an employee changes roles.
Weak or reused passwords can also increase cybersecurity risk, as seen in cases where a contractor’s compromised password led to a major HIPAA breach.
Strong authentication practices, appropriate access controls, and regular reviews should therefore be incorporated into an organization’s HIPAA risk management strategy. The goal is to limit unnecessary access while reducing the possibility that compromised credentials could expose sensitive information.
5. Overlooking Business Associate Risks
Healthcare providers frequently rely on outside organizations that may create, receive, maintain, or transmit PHI while performing services.
Ignoring these relationships is one of the HIPAA common mistakes that can leave organizations vulnerable.
Covered entities need to identify their business associates and ensure appropriate business associate agreements are in place when required. Business associates themselves also have HIPAA compliance responsibilities.
Vendor relationships should not simply be documented and forgotten. Organizations should incorporate third-party risks into their broader risk analysis and HIPAA risk management processes.
6. Using Outdated HIPAA Policies and Procedures
Having written policies does not necessarily mean an organization is compliant.
Policies and procedures need to reflect current HIPAA requirements and how an organization actually operates. A policy written years ago that no longer matches an organization’s technology, workforce, vendors, or processes may provide little protection.
Organizations should periodically review their documentation and update it when circumstances or regulatory requirements change — a core part of the keys to success for HIPAA compliance.
The HIPAA E-Tool® is designed to simplify this process by providing HIPAA policies, procedures, forms, and guidance that are updated as regulations and federal guidance change.
7. Failing to Protect PHI Across Every Format
Cybersecurity receives significant attention, but HIPAA compliance is not limited to electronic records.
PHI can exist on computers, servers, mobile devices, paper records, removable media, and other formats. Physical and administrative safeguards are therefore important alongside technical cybersecurity measures.
For example, paper records should not be left in publicly accessible areas, and organizations need a clear process to dispose of protected health information the correct way. Devices containing PHI need appropriate safeguards. Physical access to areas where sensitive information is stored should also be considered.
Effective HIPAA risk management looks at the entire environment rather than focusing on a single piece of technology.
8. Poorly Handling Potential Breaches
Organizations should know what to do when a potential privacy or security incident occurs.
Employees need a clear process for reporting suspected incidents promptly. The organization can then investigate what occurred, determine what information was involved, assess the circumstances, and follow applicable HIPAA requirements.
Waiting too long to investigate a possible breach can make an already difficult situation worse.
An incident response process should therefore be established before an incident occurs. Employees should know whom to contact and what steps they should take if they suspect PHI has been compromised. If a breach is related to ransomware, special care needs to be taken.
The HIPAA E-Tool® contains the process and forms you need: a breach risk assessment tool to help evaluate a potential breach, and all the steps to evaluate, document, and if necessary, report it to affected individuals and enforcement agencies.
How HIPAA Risk Management Helps Prevent Violations
The best way to address HIPAA common mistakes is to take a proactive approach.
Effective HIPAA risk management begins by understanding where PHI exists and what could threaten its confidentiality, integrity, or availability. Organizations can then prioritize vulnerabilities, assign corrective actions, establish deadlines, and document their efforts.
Documentation is particularly important. It helps organizations track their compliance activities and provides evidence of the steps they have taken to protect patient information.
HIPAA compliance should become part of everyday operations rather than an annual task that gets checked off a list.
Make HIPAA Compliance Easier With The HIPAA E-Tool®
Avoiding HIPAA violations requires consistent attention to risk analysis, training, policies, security practices, business associates, and documentation. Managing all of these responsibilities manually can quickly become complicated.
The HIPAA E-Tool® was developed to make the process easier.
Our web-based HIPAA compliance solution provides step-by-step guidance along with policies, procedures, forms, training resources, and interactive Risk Analysis and Risk Management tools. Organizations can identify vulnerabilities, develop action plans, track their progress, and maintain documentation in one centralized system. See the full HIPAA E-Tool features to learn more.
Whether you are a healthcare provider, health plan, business associate, or another organization responsible for protecting PHI, having an organized compliance process can help you reduce risk and avoid preventable mistakes.
Don’t wait for HIPAA violations to reveal weaknesses in your compliance program. Take a proactive approach to HIPAA risk management with The HIPAA E-Tool® and build a stronger system for protecting patient privacy.
