HIPAA Training for Audits: A Proactive Approach to Data Security

For a healthcare organization, there’s nothing more important than HIPAA compliance. It keeps your protected Health Information (PHI) confidential, intact, and always available. Plus, non-compliance can lead to fines ranging from $141 to $2.1 million for repeated violations.

HIPAA audits are a great way to ensure your team follows all the relevant regulations. Plus, it allows you to identify gaps and vulnerabilities in your current compliance strategy. This way, your organization will be fully prepared for any audits by the Office for Civil Rights (OCR).

In this guide, we’ll tell you how to conduct regular HIPAA audits as part of your 

Understanding HIPAA Audits

The Office for Civil Rights (OCR) enforces compliance with the Health Insurance Portability and Accountability Act (HIPAA). Their job is to protect the health information of patients, investigate privacy breaches, and, most importantly, conduct audits to assess an organization’s HIPAA compliance. 

There are four most common types of HIPAA audits you can expect as an organization:

• Desk Audits: In a desk audit, you just need to provide certain documentation, such as policies, procedures, and evidence of compliance, through an online portal. You must submit this within 10 business days of your organization being audited. 
• On-Site Audits: This is when an OCR auditor will visit your healthcare facilities in person. On-site audits are more comprehensive — they may interview personnel, physically inspect the facility, and observe how protected health information (PHI) is handled. These typically last 3–5 days.
• Targeted Audits: Targeted audits are triggered by certain events, such as reported violations, complaints, or prior non-compliance issues. 
• Random Audits: The OCR also randomly selects healthcare facilities for audits to understand the state of compliance across the industry. In 2016 and 2017, they evaluated 166 covered entities and 41 business associates without cause. After a short hiatus, random audits resumed in 2024.

The first step to being prepared for any type of HIPAA audit is knowing what triggers one. Here are the most common causes.

Breach Reports and Complaints

Under the Breach Notification Rule, your organization has to report PHI-related breaches to OCR. You may or may not be subject to an audit depending on the number of affected records, duration of exposure, and corrective actions taken. In 2021, OCR received 609 reports of breaches impacting approximately 37 million people.

Patient or employee complaints about HIPAA violations can also trigger audits. For instance, someone could report impermissible use or disclosure of PHI, failure to provide access to medical records, or unauthorized use of PHI for marketing. In 2021, OCR received over 34,000 such complaints — a 39% increase over five years 

Security Risk Assessments and Management

Your organization may be subject to an audit if you don’t conduct thorough risk analyses or have the right security systems for electronic PHI. OCR investigations have found that many breaches could have been prevented with proper risk assessments. 

Historical Non-Compliance

If your organization has a history of violations, you’re more likely to face follow-up audits. This allows OCR to make sure you’re adhering to Corrective Action Plans (CAPs), even imposing costly penalties for unresolved compliance issues.

Proactive HIPAA Training To Ensure Compliance 

If you want to avoid targeted audits and maintain HIPAA compliance before an audit, you’ll need to implement proactive compliance strategies. Here’s how businesses can implement HIPAA training across their workforce.

Conducting Regular Risk Assessments

OCR states that most privacy breaches can be avoided with a thorough risk assessment plan. That’s especially true for companies dealing with electronic PHI, since they’re more vulnerable to breaches. You must assess all locations where ePHI is created, received, maintained, or transmitted to find potential for cyber attacks or human error.

Once you find your system’s weaknesses, you can implement the right protections, whether that’s encryption or a firewall, and train your employees to address these risks when they arise. Most importantly, you must document the entire assessment as proof for OCR.

Developing and Maintaining Comprehensive Policies and Procedures

Did you know that inadequate policies and procedures are the most frequent reasons for failing HIPAA audits? There are three types of policies and procedures you should be focusing on:

• Privacy Rule: These cover patient rights, such as access to medical records and the right to request restrictions on disclosures.
• Security Rule: These focus on protecting ePHI through technical, administrative, and physical methods.
• Breach Notification: These policies mandate timely notification to affected patients and OCR in case of a breach.

Above all, your organization must review and update these policies regularly, especially if there has been a change in HIPAA. Experts say healthcare administrators should aim for a policy update at least once a year, even if regulations are the same.

Implementing Robust Security Measures

Whether you’re dealing with physical PHI or ePHI, your organization should have the right security measures in place for its protection. The most common choice is encryption, which protects data both in transit and at rest. 

Implementing strong access controls, such as multi-factor authentication, is another good practice since it helps prevent unauthorized access to ePHI. Companies must also keep a close eye on who’s using their network and have intrusion detection systems to identify potential breaches before they happen. 

For facilities that store physical data, having the right systems in place to prevent theft or unauthorized access is absolutely crucial. 

Employee Training and Awareness

Lastly, you must create a culture of compliance within your healthcare organization. Studies show that organizations with cybersecurity training and awareness programs show a 70% drop in security-related incidents. 

Employees must get HIPAA training on policies and procedures to understand their roles in protecting PHI. You can create online security awareness courses using tools like Coursebox to enable your employees to receive training on the go.

Preparing for a HIPAA Audit

If you’ve been informed of an upcoming HIPAA audit for your facility, here’s what you can do to prepare:

Documenting Compliance Efforts

The first thing OCR will ask in their audit is for documents to prove your compliance efforts. That’s why you must keep up-to-date documentation of policies, procedures, and employee training records. This includes compliance with the Privacy, Security, and Breach Notification Rules.

Most importantly, you should have documents of your risk assessments. In 2017, 66% of organizations didn’t have the right risk assessment documents, which can increase your chances of failing. Lastly, don’t forget to keep valid Business Associate Agreements (BAAs).

Conducting Internal Audits

You can also conduct internal audits to find gaps in your compliance efforts before the actual audit actually happens. HIPAA checklists and online compliance courses are great ways to find out what’s missing in your current strategy. Regular internal audits can uncover deficiencies in areas like encryption or multi-factor authentication (MFA), which 50% of organizations fail to implement.

Developing an Audit Response Plan

Your facility’s compliance officer will act as a point of contact between you and OCR. Make sure they have access to the relevant documentation, such as training records, security logs, and incident reports. They should also be prepared to answer any questions about your organization’s HIPAA policies and procedures confidently.

Understanding The Audit Process and What to Expect

During audits, OCR will asses your organization’s compliance with administrative, physical, and technical mentioned in HIPAA. Common focus areas include encryption (lacking in 26% of organizations) and email security (27% non-compliant). They will also review your risk assessments, BAAs, incident handling records, and policies for notifying affected patients in case of breaches.

Post-Audit Actions and Continuous Improvement 

Your efforts don’t end once you pass your audit. In fact, HIPAA compliance should be an ongoing practice — not just in preparation for OCR visits. Here are some tips to keep in mind after the audit:

1. Organizations must create a Corrective Action Plan (CAP) based on the audit findings. This plan will outline the exact steps taken to resolve identified issues, assign responsibilities, and set deadlines. OCR may ask for this plan in follow-up reviews.
2. Policy reviews should be an ongoing effort, even if official regulations haven’t changed. More importantly, your business must keep a close eye on the access logs to see who’s using your network and catch potential data breaches early on.
3. Leaders at your healthcare facility should create a culture of compliance where employees feel comfortable reporting potential violations without fear of retaliation. More importantly, they should be trained to reinforce patient privacy with the help of online courses on Coursebox. 
4. Organizations must stay informed about changes to HIPAA regulations through the HHS website, industry newsletters, or compliance software tools. HIPAA has been updated as recently as 2025.

Conclusion

Staying ahead of HIPAA audits has more benefits than just avoiding penalties — you’ll also be able to retain patient trust by protecting their privacy. A proactive approach, with regular checks and solid training, makes all the difference. 

If you want to make HIPAA training less of a headache for your team, use Coursebox to create easy online courses that make compliance easier.