Compliance Advisory Services

The HIPAA Security Risk Assessment process varies depending on several factors, including the size of the organization, complexity of systems, and existing security measures. However, here is a general breakdown:

Time Estimates Based on Organization Size

• Small organizations (e.g., clinics, private practices):
  • Typically: 2 to 6 weeks
  • Faster if using automated tools
  • Less complexity, fewer systems to evaluate

• Mid-sized healthcare providers (e.g., hospitals, specialty centers):
  • 8 weeks to 3 months
  • Requires extensive system reviews and staff interviews
  • May include external consultants like ITS Alliances

• Large health systems & business associates (e.g., hospital networks, insurance companies):
  • 3 to 6 months (or longer)
  • Comprehensive analysis, multiple locations, detailed security layers
  • Continuous monitoring required

Factors Affecting Duration

1. Scope of Analysis – More data, systems, and locations = longer process.
2. Regulatory Requirements – Some industries require deeper evaluations.
3. Existing Security Measures – Stronger cybersecurity frameworks can shorten analysis time.
4. Availability of Documentation & Personnel – Access to logs, policies, and staff speeds up analysis.
5. Use of Automated Tools – AI-driven assessments can reduce manual effort.

While a full analysis can take weeks or months, organizations should continuously monitor and update their risk assessments to stay compliant.

Once a HIPAA Security Risk Assessment is completed, organizations move into the remediation and compliance improvement phase to address identified risks. Here is what typically happens next:

1. Review Findings & Prioritize Risks
   – Analyze the analysis report to understand vulnerabilities.
   – Rank risks based on severity and likelihood.
   – Focus first on critical security gaps that could lead to HIPAA violations.
   
2. Develop a Remediation Plan
   – Create a strategy to mitigate identified risks.
   – Implement technical safeguards (e.g., encryption, access controls).
   – Strengthen administrative policies, including staff training.
3. Implement Security Enhancements
   – Deploy solutions to reduce vulnerabilities.
   – Update software and configure security systems.
   – Employee training on data protection and privacy.
4. Monitor & Maintain Compliance
   – Perform ongoing security assessments.
   – Conduct regular audits to ensure continued HIPAA compliance.
   – Keep documentation updated for potential audits or investigations.
5. Report Compliance Efforts
   – Prepare compliance reports for auditors or leadership.
   – Maintain documentation of security controls, corrective actions, and policies.
   – Ensure all business associates are also following HIPAA guidelines.
6. Continuous Improvement
   – Adapt to new cybersecurity threats and regulations.
   – Update security policies based on evolving best practices.
   – Ensure proactive risk management to prevent future violations.HIPAA compliance is an ongoing effort—organizations must regularly review and strengthen security measures to protect electronic protected health information (ePHI).

ITS Alliances services play a crucial role in supporting a covered entity or business associate after a breach involving protected health information (PHI) has been identified. The responsibilities are outlined under HIPAA regulations, specifically the Breach Notification Rule.

Typical Support Provided:

1. Immediate Notification – Depending upon whom was breached we must notify HHS without unreasonable delay, and no later than 60 days after discovering the breach.
2. Detailed Breach Information – Reports to provide details such as:
   – The nature and extent of the breach.
   – The individuals affected.
   – Any mitigation efforts taken.
3. Risk Assessment & Investigation – We would assist in evaluating the impact of the breach and determining whether ePHI was compromised.
4. Media Notification – If the breach affects 500 or more residents in a single state, the entity must notify prominent media outlets to ensure public awareness. We would create the public press release and work with each media outlet as needed.
5. Mitigation & Corrective Actions – Depending upon the impact of the breach, implement security improvements, conduct employee training, and revise policies and/or procedures to prevent future breaches.

• Software-as-a-Service Platform (#of users and # of Assets to monitor)
• HIPAA Consulting Service by Hour, Contract or Privacy Officer
• Auditing and monitoring of the Privacy Program
• Risk Analysis and Risk Assessment
• Policy & Procedures Development
• Privacy Program Updates to comply with HIPAA regulations
• Incident and Breach reporting
• Excellent Customer Service and Support