HHS Selects FCi Federal to Run Second Round of HIPAA Audits

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By James Swann

Oct. 27 — FCi Federal, a government services provider in Ashburn, Va., has been hired by the federal government to conduct the second round of HIPAA audits, a health and human services official said Oct. 27.

Jocelyn Samuels, director of the Department of Health and Human Services Office for Civil Rights, said the audits will begin shortly, though she didn't provide an exact date.

“We've been verifying contact information for the business associates and covered entities that will be included in the Phase Two audits,” Samuels said at the Health Care Compliance Association's Enforcement Compliance Institute.

Phase Two will consist primarily of desk audits, Samuels said, but there will be some on-site audits as well.

The OCR will release an audit protocol closer to the start of the audits, she said.

The first phase of the HIPAA audits was conducted as a pilot program in 2011 and 2012. The compliance audits are intended to determine if health-care organizations and their contractors are complying with HIPAA privacy and security rules.

Breach Reports

Beyond the upcoming HIPAA audits, Samuels also discussed the OCR's role in collecting breach reports. Between September 2009 and Oct. 9, Samuels said the OCR received approximately 1,355 large breach reports, meaning the breach affected more than 500 individuals.

Over the same time frame, the OCR received more than 181,000 small breach reports, meaning the breach affected fewer than 500 people.

Theft and loss accounted for 57 percent of all large data breaches, Samuels said, and 31 percent of large breaches were associated with a lost or stolen laptop computer or other personal storage device.

Samuels said the theft or loss of paper records accounted for 21 percent of the large data breaches.

In addition to the breach reports, Samuels said the OCR received 34,613 complaints alleging violations of the HIPAA privacy, security or breach notification rules between April 14, 2003 and Aug. 31. The OCR developed correction plans with health-care organizations for 69 percent of the complaints.

Typical corrective actions include requiring a covered entity to perform a risk analysis, review and revise all policies and procedures, train employees and monitor compliance, Samuels said.

Samuels said the OCR likes to informally resolve complaints but will move on to formal resolutions where necessary.

Recurring Issues

Samuels said there are several recurring issues the OCR sees in organizations that suffer data breaches, including:

• failure to have business associate agreements;

• failure to perform an enterprise-wide risk analysis;

• failure to manage identified risks;

• lack of data transmission security;

• lack of appropriate auditing;

• no software patching;

• insufficient data backup; and

• improper data disposal.


To contact the reporter on this story: James Swann in Washington at jswann1@bna.com

To contact the editor responsible for this story: Kendra Casey Plank at kcasey@bna.com