The Department of Health and Human Services’ Office for Civil Rights (OCR) is reviving its HIPAA audit program, and Texas medical practices are squarely in scope. OCR has signaled audits will resume in 2024, focusing on whether covered entities and business associates can prove their administrative, technical, and physical safeguards are more than paperwork.
The stakes are steep. Recent enforcement actions have ranged from $100,000 settlements for incomplete risk analyses to multi-million dollar penalties for systemic failures. Civil penalties can reach $50,000 per violation, per year of neglect.
This checklist synthesizes the HIPAA Security Rule, Privacy Rule, and Breach Notification Rule into practical steps you can execute now, plus a 30-day sprint for catching up fast. Use it to confirm your documentation, close gaps, and enter 2025 knowing you can hand auditors whatever they request.
What OCR Actually Audits
Auditors focus on three frameworks: the Security Rule, the Privacy Rule, and the Breach Notification Rule. Covered entities (providers, clinics, hospitals) and business associates (billing services, MSPs, cloud vendors) must demonstrate policies, proof of implementation, and continuous improvement.
Audits occur randomly or after complaints and breaches. OCR typically gives 10 business days to submit documentation, so being “almost compliant” is not enough; you need evidence organized today.
Privacy Rule: Policies and Notices
Notice of Privacy Practices (§164.520)
Ensure your Notice of Privacy Practices is up to date, posted in waiting rooms, available on your website, and provided to new patients. Document acknowledgements and track updates whenever you change how information is used or shared.
Patient Rights (§164.524–528)
Create procedures for responding to access requests within 30 days, processing amendments, logging disclosures, and honoring restrictions or confidential communication requests. Keep logs showing request dates, fulfillment timelines, and communications.
Minimum Necessary (§164.502(b))
Document role-based access for EHRs, billing systems, and cloud storage. Train staff to use minimum necessary data, and audit user activity to verify adherence.
Business Associate Agreements (§164.502(e))
Inventory every vendor handling protected health information (PHI), verify signed BAAs, and review them annually. Keep termination procedures for vendors leaving your ecosystem.
Security Rule: Administrative, Physical, and Technical Safeguards
Administrative Safeguards (§164.308)
Perform an annual risk analysis (§164.308(a)(1)(ii)(A)) covering EHRs, telehealth platforms, mobile devices, and cloud services. Document mitigation plans with owners and deadlines. Maintain policies for workforce training, sanctions, contingency planning, and security evaluations. Equip staff with practical education using resources like our Security Awareness Training Kit to reinforce phishing, password, and incident reporting expectations.
Physical Safeguards (§164.310)
Control facility access, secure workstations, and track device/media movement. Use badge logs, visitor sign-ins, locked server rooms, and documented media disposal procedures.
Technical Safeguards (§164.312)
Implement unique user IDs, automatic logoff, encryption, and audit logging. Enable MFA for remote access, use EDR on all endpoints, and review access logs regularly.
Breach Notification Rule
Understand the definition of a breach (§164.402) and the four-factor risk assessment. Prepare patient notification templates, media statements for incidents affecting 500+ individuals, and submission workflows for the HHS breach portal. Maintain a log of incidents affecting fewer than 500 individuals for annual reporting.
Documentation Standards
HIPAA requires keeping documentation for six years (§164.530(j)). Organize policies, risk analyses, training logs, incident reports, audit findings, and BAAs in a secure repository with version control. Use consistent naming conventions and index files so you can respond to audit requests within days.
Common Medical Practice Gaps
- Outdated or incomplete risk analyses.
- Missing BAAs for marketing agencies, MSPs, or telehealth vendors.
- Shared logins and lack of MFA for EHR access.
- Unencrypted laptops and mobile devices.
- No evidence of log review, backup testing, or incident response drills.
- Incomplete training records—verbal reminders do not count.
- Delayed termination of user accounts after staff departures.
- Bring-your-own-device (BYOD) policies lacking enrollment, encryption, and remote wipe controls.
30-Day HIPAA Compliance Sprint
Week 1
- Update or complete your risk analysis.
- Inventory PHI systems and confirm backup coverage.
- Gather and review BAAs—request missing agreements immediately.
Week 2
- Refresh policies, note version numbers, and capture leadership approvals.
- Designate security and privacy officials with documented responsibilities.
- Ensure unique IDs and MFA are enforced for EHR, billing, and remote access.
Week 3
- Collect training attendance records and schedule sessions for gaps.
- Test backups, record results, and remediate failures.
- Review user access lists with department leads and disable stale accounts.
Week 4
- Activate log monitoring and document review cadence.
- Finalize breach response procedures, including contact lists and notification templates.
- Organize documentation folders and create an audit index for quick retrieval.
Need Help? Download Our HIPAA Readiness Toolkit
We package policies, training rosters, risk analysis templates, and incident forms into a single checklist. Access it from our resources hub, or invite us to walk through the toolkit with your compliance committee.
Maintaining Ongoing Compliance
Schedule annual risk analyses, security program evaluations, and workforce training. Conduct quarterly access reviews, log monitoring, and policy refreshes. Test disaster recovery plans annually and document corrective actions. Submit breach logs to HHS within 60 days of year-end for incidents affecting fewer than 500 individuals.
Leverage technology to automate evidence collection—ticketing platforms for access changes, learning management systems for training, and documentation tools for policy versioning. Our compliance & risk management team manages these workflows for clinics statewide, ensuring nothing falls through the cracks.
When to Bring in Outside Expertise
Consider external support if your risk analysis is outdated, if you’ve experienced a breach, if rapid growth has outpaced policy enforcement, or if you lack bandwidth to keep documentation current. Fractional compliance officers and managed security providers can shoulder the burden while your staff focuses on patient care.
Review recent OCR resolution agreements for guidance on enforcement trends. Many settlements cite lack of risk analysis, insufficient logging, and incomplete BAAs—the same areas we emphasize in every engagement.
Conclusion
HIPAA compliance is achievable with discipline, documentation, and leadership buy-in. Focus on fundamentals: accurate risk assessments, enforceable policies, documented training, and tested incident response plans. With those pieces in place, audits become validation rather than disruption.
Our Texas-based team provides risk analyses, policy development, training programs, and continuous monitoring—bundled under one transparent partnership so clinics never worry about surprise invoices. We’ll walk into audits with you and ensure every answer is backed by evidence.
Ready to confirm your readiness? Schedule a HIPAA gap assessment or call 210-343-5631. We’ll bring the checklists, templates, and expertise so you can stay focused on patient outcomes.