The HIPAA Security Risk Assessment - Physical Safeguards
The Health Insurance Portability and Accountability Act (HIPAA) Security Rule sets forth a set of standards for protecting the confidentiality, integrity, and availability of electronic protected health information (ePHI).
HIPAA Physical Safeguards, the measures taken to protect the physical security of PHI and ePHI, are an essential component of this rule.
Physical safeguards are put in place to prevent unauthorized access to PHI, whether intentional or unintentional. They ensure that physical access to systems, equipment, and facilities that contain PHI is restricted to authorized personnel. Physical safeguards also protect against environmental hazards such as fire, water damage, and theft.
The following are four critical physical safeguards that must be implemented to protect ePHI:
- Facility Access Controls
- Workstation Security
- Device and Media Controls
- Disaster Recovery
Facility Access Controls
These are the measures used to control and monitor access to facilities where ePHI is stored or processed. Physical access controls include procedures for granting access to facilities, identifying individuals, and controlling entry to and exit from the facility. The following are the key components of facility access controls:
Facility Security Plan
A facility security plan is a comprehensive plan that outlines the procedures and policies for safeguarding PHI within a facility. It includes physical security measures such as access controls, identification procedures, and emergency response plans.
Access Authorization
Access authorization is the process of granting individuals access to a facility or area where PHI is stored or processed. Access authorization procedures must be established and followed to ensure that only authorized personnel are allowed access to protected areas.
Maintenance Records
Maintenance records are the documentation of all maintenance activities related to physical security controls. Maintenance records should be kept for all security controls and include information such as the date of maintenance, the person performing the maintenance, and any issues that were discovered.
Workstation Security
These are measures used to protect workstations, servers, and other devices that store, process, or transmit ePHI. Workstation and device security controls are designed to protect ePHI from unauthorized access, use, or disclosure. The following are the key components of workstation security:
Workstation Use Policy
A workstation use policy is a set of rules that outlines the acceptable use of workstations that store or process ePHI. The policy should include guidelines for the use of removable media, email, and internet access.
Workstation Area
Before an individual even encounters your password protection, physical access to workstations should be limited only to authorized personnel.
Device and Media Controls
These are the measures used to manage the use of electronic media that store ePHI. Device and media controls include procedures for the secure disposal and inventory of electronic media. The following are the key components of device and media controls:
Disposal Procedures
Disposal procedures are the procedures for disposing of electronic media that contain ePHI. Electronic media should be securely erased or destroyed to prevent unauthorized access to ePHI.
Media Re-use
Covered entities must implement policies and procedures for the re-use of electronic media that contains PHI. These policies should ensure that all PHI is removed from the media before it is reused. Common re-use procedures include erasing or overwriting data on the media.
Device Tracking
Covered entities must implement procedures for tracking the movement of electronic devices and media that contain PHI. These procedures should ensure that only authorized personnel have access to the devices and media and that their movement is recorded and tracked. Common accountability measures include keeping an inventory of all electronic devices and media, using access controls to limit access to authorized personnel, and implementing tracking systems to monitor the movement of devices and media.
Training
All personnel who handle electronic devices and media that contain PHI should receive regular training on HIPAA requirements for device and media controls. This training should include the proper handling, storage, and disposal of electronic devices and media.
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How Medcurity Helps:
Medcurity provides complete compliance training for employees of healthcare providers on what they need to know to protect ePHI. Courses are updated regularly to reflect current regulations, with knowledge checks and quizzes throughout. You can manage and oversee staff training progress on Medcurity’s easy-to-use dashboard.
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Disaster Recovery
These are the measures taken to prepare to continue operations in an emergency situation, where access to PHI may be limited or cut off. The following are the key components of disaster recovery controls:
Contingency Plan
Covered entities must implement a contingency plan that addresses the steps to be taken in case of a disaster or other emergency that affects the availability of PHI. The contingency plan should include backup and recovery procedures, emergency access procedures, and continued care procedures. Disaster recovery procedures should include the restoration of data from backups, the repair or replacement of damaged equipment, and the restoration of data access.
Regular Testing
Covered entities should test their backup and disaster recovery procedures regularly to ensure their effectiveness. Testing should include the restoration of data from backups, the activation of emergency mode operations, and the restoration of data access.
Offsite Storage
Covered entities should store their backups in an offsite location to ensure their safety in case of a disaster or other emergency that affects the physical infrastructure of the healthcare organization.
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How Medcurity Helps:
The Medcurity Security Risk Assessment walks you through a complete analysis of your HIPAA administrative, technical, and physical safeguards. As your one-stop shop for HIPAA compliance tools and resources, Medcurity prioritizes keeping all assessments updated to meet current government requirements.
Our complete guided HIPAA Security Risk Assessment platform is intuitive and easy to use. Covered entities and business associates can save time and decrease their chances of facing the costly effects of a breach by conducting a full SRA themselves, or can utilize Medcurity SRA services to get an expert third party’s look into their compliance efforts.
All the input from the SRA is gathered into one list of prioritized action items so that you can immediately begin taking the best next steps to protect the security of your data. These steps can be assigned to specific users and tracked from the Medcurity dashboard, so you get the most out of your assessment.
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If you have further questions regarding the administrative, physical, and/or technical safeguards required by HIPAA, please reach out to your team at Medcurity. We’re here to help you simplify HIPAA compliance so that you can focus on providing the best patient care.