Breaking Down A HIPAA Corrective Action Plan


HIPAA violations can take a costly toll on your business. When people think about HIPAA violations, they probably picture millions of dollars of fines. Sure, fines would take a toll on your organization. But in addition to fines, the Office for Civil Rights (OCR) will also seek a resolution agreement and enforce a HIPAA corrective action plan (CAP), which is more burdensome, time-consuming, and constantly monitored. 

This HIPAA enforcement applies to both covered entities (CEs) and business associates (BAs) as well. 

Of course, you want to avoid a corrective action plan in the first place. The only way to prevent this is to follow HIPAA rules and regulations correctly. Pretty straightforward.

What Is a HIPAA Corrective Action Plan (CAP)?

A HIPAA corrective action plan is designed to manage the specific vulnerabilities uncovered during an audit or investigation and usually lasts for about one to three years. The purpose is to find underlying security issues within your practice and make you correct them. Corrective action plans allow OCR to look over the shoulder of violators and ensure that they comply.

If you don’t comply with the CAP, you will violate the resolution agreement and possibly be fined further. 

A HIPAA corrective action plan will require you to establish specific procedures to address the violations discovered by the OCR, which could have been prevented if a proper risk analysis was performed in the first place. It includes performing a closely monitored risk analysis and developing a risk management plan. The plan may also include training your employees on security measures and policies.

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While the CAP is in place, the OCR will also require the organization to submit regular reports of implementation and annual reports of their efforts. Usually, OCR does the oversight but sometimes requires the organization to hire a third-party to monitor their compliance. It’s all very costly, burdensome, and time-consuming.

Usually, HIPAA corrective action plans include:

  • Conducting risk analyses every year,
  • Developing and implementing a risk management plan,
  • Reporting events that could lead to HIPAA violations,
  • Maintaining documentation for at least six years.

Other specifications will be included in the plan according to the organization’s weaknesses. Some examples are better management of business associates, workforce training, or updated policies.

Avoiding CAPs

Not performing risk analysis is one of the most common reasons organizations get hit with fines and penalties. Conducting proper risk analysis helps organizations to uncover the areas of risks and vulnerabilities and provides them a path to reduce them. A healthcare business should already have all the components of a CAP in place. 

The only thing you can do is stay compliant with HIPAA. Even if you are compliant, the OCR might audit you and will require you to provide documentation of risk analyses and compliance efforts. If you are compliant, you have a much better chance of avoiding penalties.

Nevertheless, proactively pursuing HIPAA compliance is far more cost-effective than spending millions of dollars in fines and enforcing a corrective action plan.

One Platform for Your Computers, Tablets, and Smart Phones to Manage HIPAA Compliance

Strict compliance with HIPAA corrective action plan is crucial. HIPAA Ready is the best HIPAA compliance software to streamline obligatory requirements, such as risk analysis, training, policy management, and much more.

Even after you have received penalties, you can still make use of HIPAA Ready to ensure your CAP efforts don’t deviate from the plan. With HIPAA Ready, you can easily report incidents that may be suspicious, conduct regular risk analysis, assign and provide training to employees, and even retain information for more than 6 years. Above all, it is 100% customizable and the platform can be personalized according to your business needs. All it takes is just $10/user/month.

To learn more about HIPAA Ready, get in touch with us today, or leave a comment below. Let us help you avoid the pain! 

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