HIPAA employee training

The regulations relating to HIPAA training for employees are deliberately flexible because of the different functions Covered Entities perform, the different roles of employees, and the different level of access each employee has to Protected Health Information (PHI). The degree of flexibility might lead to misunderstandings regarding whether employees require training, what training should be provided, how training should be provided, and when training should be provided.

Both the HIPAA Privacy Rule and the HIPAA Security Rule requires that all members of the workforce undergo training. This includes not only employees, but also agency staff, consultants, and contractors, regardless of their level of interaction with PHI – even if they have no contact at all.

The HIPAA Security Rule, on the other hand, applies to both Covered Entities and Business Associates, whereas the HIPAA Privacy Rule only applies to Covered Entities. As a result, Business Associates must only implement the Security Rule’s security awareness and training programme, ensuring that all members of the workforce get HIPAA training regardless of their role or function.

Each Covered Entity is required by the HIPAA Privacy Rule to develop policies and procedures designed to comply with the Rule’s standards and implementation specifications, as well as “train all members of its workforce on the policies and procedures as necessary and appropriate for the members of the workforce to carry out their functions within the Covered Entity.” This implies that the content of HIPAA training will be determined by the Covered Entity’s policies and procedures, as well as the policies and procedures that are relevant for each employee to perform their duties in accordance with HIPAA.

Covered Entities must conduct HIPAA policy and procedure training “within a reasonable time after a person joins the Covered Entity’s workforce” and whenever “functions are affected by a material change in the policies or procedures.” There is no time period for when a security awareness and training programme must be undertaken. Additionally, Covered Entities and Business Associates should incorporate HIPAA employee training into risk assessments. This will aid in determining whether additional training is required for members of the workforce to prevent unauthorised uses or disclosures of PHI that have resulted from poor practices. If a training requirement is identified, it must be fulfilled “within a reasonable period of time.”

In order to assess whether HIPAA training is required, Privacy and Security Officers should:

  • Develop a HIPAA refresher training program that can be conducted at least annually to reinforce the need to comply with HIPAA Rules.
  • When new rules or guidelines are issued, conduct a risk assessment to determine how they will affect the organization’s operations and if HIPAA training is required.
  • Conduct regular risk assessments to identify how material changes in policies or procedures may increase or decrease the risk of HIPAA violations.
  • Liaise with HR and Practice Managers to receive advance notice of proposed changes in order to determine their impact on compliance with the HIPAA Privacy Rule.
  • Liaise with IT managers to receive advance notice of hardware or software upgrades that may have an impact on compliance with the HIPAA Security Rule.

HIPAA Compliance Training contents:

The suggested modules of a HIPAA training course are divided into two groups: basic and advanced. The fundamental aspects that should be covered in a HIPAA training session are suitable as an introduction to HIPAA or as the foundation for a refresher course. Those in the advanced training category can be utilised to supplement trainees’ HIPAA knowledge or tailored to provide more role-specific understanding.

Basic HIPAA compliance training should include – 

  • HIPAA Overview
  • HIPAA Definitions
  • The HITECH Act
  • The Main HIPAA Regulatory Rules
  • HIPAA Omnibus Final Rule
  • HIPAA Privacy Rule Basics
  • HIPAA Security Rule Basics
  • HIPAA Patient Rights
  • HIPAA Disclosure Rules
  • HIPAA Violation Consequences
  • Preventing HIPAA Violations
  • Being a HIPAA Compliant Employee

Advanced HIPAA compliance training should include – 

  • HIPAA Timeline
  • Threats to Patient Data
  • Computer Safety Rules
  • HIPAA and Social Media
  • HIPAA and Emergency Situations
  • HIPAA Officer roles and responsibilities
  • HIPAA Compliance Checklist
  • Recent HIPAA Updates
  • Cybersecurity Dangers for Healthcare Employees
  • How to Protect PHI from Cyber Threats

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