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This exercise is intended to illustrate how prepared your clinic would be if a Health & Human Services representative were to visit or contact you.
Does your staff know who they are and when/how to contact them?
Have they documented your required risk mitigation plan this year to identify any security/privacy gaps and completed a remediation plan to resolve them?
Has your Compliance Officer been periodically updating and maintaining the required documentation for your risk management/remediation plan?
Has every staff member attested to having read and understood this manual?
Did you conduct a test of your documented procedures for your Contingency Plan this year?
Have you had a breach in the past year?
If you had a breach, did you report it following your documented HIPAA procedures?
Has your Compliance Officer trained your entire staff of owners, managers,admin, and employee-based providers this year?
Has your Compliance Officer, or anyone else, trained your contract providers on HIPAA?
Do you have documented proof of everyone's completed training?
Did you review/update the BAA this year to see if it contains the current required HIPAA content?
Did you re-verify this year that each Business Associate is HIPAA-compliant?