How will the Phase 2 HIPAA audit program work?

OCR plans to conduct desk and onsite audits for both Covered Entities and their Business Associates. The first set of audits will be desk audits of covered entities followed by a second round of desk audits of business associates. These audits will examine compliance with specific requirements of the Privacy, Security, or Breach Notification Rules and auditees will be notified of the subject(s) of their audit in a document request letter.  All desk audits in this phase will be completed by the end of December 2016.

The third set of audits will be onsite and will examine a broader scope of requirements from the HIPAA Rules than desk audits. Some desk auditees may be subject to a subsequent onsite audit.

The audit process will employ common audit techniques. Entities selected for an audit will be sent an email notification of their selection and will be asked to provide documents and other data in response to a document request letter. Audited entities will submit documents on-line via a new secure audit portal on OCR’s website. There will be fewer in-person visits during these Phase Two audits than in Phase One, but auditees should be prepared for a site visit when OCR deems it appropriate.  Auditors will review documentation and then develop and share draft findings with the entity.  Auditees will have the opportunity to respond to these draft findings; their written responses will be included in the final audit report.  Audit reports generally describe how the audit was conducted, discuss any findings, and contain entity responses to the draft findings.

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