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    HIPAA compliance checklist for medical spas

    HIPAA compliance checklist

    HIPAA. HIPAA regulations. HIPAA compliance. HIPAA obligations. Sounds familiar? 

    If you are a medical spa or any other healthcare organization for that matter, you have probably heard the HIPAA talk by now. And you’ve heard it for a good reason because HIPAA compliance for med spas is not only a must-know but also a must-implement regulation. 

    As a medical spa, you might have implemented different security measures by now, such as 2FA authentication, to protect sensitive process information. But when it comes to protecting sensitive patient data, be it patient IDs or treatment details, HIPAA is the only US regulation to legally enable — and demand — this. 

    Navigating HIPAA compliance, especially with ever-changing US security regulations, can be tricky — but it’s necessary to do. 

    To make things easier, we prepared a guide to help you learn — 

            👉 What HIPAA compliance is and its aims

            👉 Why your medical spa needs HIPAA compliance and who else needs it

            👉 How HIPAA benefits your medical spa and manages violations

            👉 What you need to do to ensure HIPAA compliance

            👉 How HIPAA compliance works with Pabau 

    If you are already acquainted with HIPAA compliance, jump to our summarized checklist of steps you have to fulfill.  But, if you need to learn HIPAA compliance in-depth, let’s start from the beginning.

    What is HIPAA?

    HIPAA, or the Health Insurance Portability and Accountability Act of 1996, is a federal law designed to protect sensitive patient data in the US. It is a mandatory compliance for healthcare businesses aiming to secure sensitive patient data, otherwise known as Protected Health Information (PHI). Key information that fall under PHI include the patients’: 

    • Name and address
    • Social Security number (SSN)
    • Date of birth (DOB)
    • Email, phone number, and fax
    • Medical records or account numbers
    • Facial images (particularly important for your practice!)
    • Fingerprints and IP addresses
    • Health plan beneficiary numbers
    • Vehicle indicators, like license plates

    Ensuring HIPAA compliance is not a one-time thing. Rather, it is an ongoing process of implementing proper data protection, be it by conducting regular risk assessments and extensive staff training, investigating, reporting, or else.

    HIPAA’s main objectives

    95% of identity thefts come from stolen healthcare records. But, with HIPAA in place, your practice can:

    To ensure proper HIPAA compliance, healthcare organizations of all backgrounds need to become familiar with the five rules HIPAA imposes.

    1. Privacy rule — regulates how PHI is used and disclosed
    2. Security rule — regulates physical, technical, and administrative security measures
    3. Enforcement rule — enforces liability and imposes penalties for violations
    4. Breach notification rule — shares guidelines on managing and reporting violations
    5. Omnibus rule — details how business associates should handle PHI

    Who needs to be HIPAA compliant

    Two types of businesses need HIPAA compliance: covered entities and business associates.

    Covered entities 

    These include individuals and organizations that are obligated to comply with HIPAA privacy and security rules, including:

       ✅ Hospitals and pharmacies

       ✅ Medical spas

        Clinics and practices

       ✅ Doctors, dentists and chiropractors 

       ✅ Psychologists and psychiatrists

       ✅ Healthcare providers

       ✅ Health insurance companies


    Business associates 

    On the other hand, have PHI access and provide services to the covered entities we listed. Business associates can include: 

       ✅ Billing companies, in charge of processing claims or managing patient accounts

       ✅ Electronic health record (EHR) vendors that host or manage EHR systems for you

       ✅ IT providers or any software offering technical support, data storage, cloud or cybersecurity services for your spa

       ✅ Consultants, attorneys, and auditors with access to your patients’ PHI 

    Besides these, subcontractors who collaborate with business associates, and handle covered entities’ PHI, may also need to comply with HIPAA. This rule falls under the Business Associate Chain concept.

    HIPAA violations penalties

    HIPAA imposes mandatory legal compliance for medical spas. Disobeying HIPAA regulations, or violating your compliance is penalized by law —  

    Different types of HIPAA violations that are subject to fines include:

       ❌ Unauthorized use & disclosure of PHI

       ❌ Failing to comply with patients’ protection rights

       ❌ Not sharing privacy practices with patients

       ❌ Not training employees on HIPAA compliance

       ❌ Not conducting risk analysis

       ❌ Not having a contingency plan in place

       ❌ Lacking physical or technical safeguards

       ❌ Failing to meet agreements with business partners

       ❌ Not complying with transactions provisions or audit control standards

    HIPAA violation cases — Examples to learn from

    Ensuring a certain level of encryption doesn’t always ensure direct HIPAA compliance.

    Related:  5 Pabau secrets to reduce no-shows in your clinic, salon or spa

    This unawareness has led many medical spas to become subject to compliance violation.
    In the US, HIPAA violation investigations are typically managed by the U.S. Department of Health and Human Services (HHS), and the Office for Civil Rights (OCR). 

    Let’s look at some examples of healthcare organizations that faced HIPAA violations. 

    L.A. Care Health Plan, for example, a local healthcare agency, recently faced two HIPAA investigations for not conducting proper risk analysis, maintaining security measures, and reporting breaches. These violations ultimately led to the disclosure of 1,498 individuals’ ePHI, which then resulted in a violation settlement worth $1.3 million.

    Another example is UnitedHealthcare, a health insurer from Minnesota. After a patient complained about not receiving their medical records due to an employee error, UnitedHealthcare was found to have violated the HIPAA Right of Access, resulting in an $80,000 fine.

    Finally, there’s iHealth Solutions, a Kentucky-based HIPAA business associate that suffered an unauthorized access incident in 2017. This incident included 267 individual PHIs and was the result of an unsecured server and poorly conducted risk analysis.
    By the end, the company was fined for their violation and reached a $75,000 settlement. 

    Why HIPAA compliance for medical spas is a ‘must’

    Aside from practices, clinics, and hospitals, medical spas are also subject to HIPAA compliance. The reason for this is because, just like other healthcare and beauty organizations, medical spas also manage protected client information (PHI) such as:

    • Patient before-after photos & iPad data
    • Patient treatment journeys & plans 
    • Patient consent forms & consultation notes
    • Personal patient information, like names, numbers, and addresses
    • Patient payment information 

    Does Pabau support HIPAA compliance for medical spas?

    Yes, Pabau supports HIPAA compliance for all US-based medical spas that need to adhere to HIPAA regulations. However, keep in mind that supporting HIPAA compliance and enforcing it are two different things. 

    Enforcing HIPAA compliance includes several steps that medical spa needs to fulfill on their own. In other words, all relevant processes, like reporting and doing risk analysis are the sole obligation of the medical provider (that’s you!), not Pabau. 

    But, when using a designated CRM for your business, like Pabau, you need to make sure that your enforced compliance is activated and running in the system properly. 

    To support your HIPAA compliance, Pabau created various relevant features. 

    For example, we offer a Pabau HIPAA compliance support toggle, which, when turned on, automatically runs your HIPAA compliance. To get started, go to Setup➡️Business details➡️Security. Switch the HIPAA toggle on. All done!

    The benefits of Pabau HIPAA compliance for medical spas

    First off, HIPAA allows Pabau medical spas to give patients greater control of their data. It also regulates how your patient EHRs will be managed while setting clear guidelines for you to meet. 

    Let’s go over the key ways Pabau can support HIPAA compliance. 

    1. Easier compliance management 

    Pabau’s HIPAA compliance feature reduces the need for additional paperwork. By simply using the toggle switch, you can automatically activate HIPAA compliance and never worry about it again. Of course, to be sure of full-on HIPAA compliance, you first need to follow through with all required compliance steps.  

    2. Secure online booking and sharing 

    Pabau HIPAA compliance for medical spas makes your online bookings safer. It protects personal health information (PHI) shared during online bookings and reduces the risk of unauthorized access or breaches. The same level of security applies to protecting personalized patient treatment plans, lab results, files, and medical history details. 

    For example, HIPAA compliance allows you to safely share before-after photos with patients, monitor the patient journey via iPad, and safely manage consent forms.

    3. Data encryption, secure storage, and access control

    Pabau uses special encryption protocols to keep patient information safe, whether you share or store it. Information such as medical records and contact details, will stay private and be hard to access without user authorization. You can also make sure that only the right people can see sensitive patient info, like specific doctors, for example.

    4. Audit logs

    Pabau’s system uses an audit logs feature to track all user activities and record the details in one place. So, if a security breach occurs, or someone gets unauthorized access to patient information and changes it, your medical spa will be immediately alerted. 

    Having a comprehensive activity log helps you swiftly investigate and resolve security issues, ensuring you stay in compliance with important HIPAA regulations.

    Alongside HIPAA, Pabau also performs regular data backups and disaster recovery protocols, in case of an unwanted incident or breach. We also enforce comprehensive employee training to ensure that our staff is acquainted with the best privacy practices.

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    A HIPAA checklist for medical spas

    Managing HIPAA compliance for medical spas can be complex, especially if it’s your first time doing it.

    Often, HIPAA violations might happen without people even realizing they are breaching compliance. 

    But, whether it is due to neglect, a mishap, or an oversight, violating HIPAA compliance is the last thing you want to do. Not only will you break the trust you built with patients, you will also cause serious damage to your reputation, and become subject to penalties.   

    Before we explain HIPAA compliance in detail, here’s a quick checklist of all basic steps you will need to complete to meet it. 

    HIPAA compliance checklists for medical spas

    To prevent you from missing any crucial steps along the way, we share a detailed guide to help ensure successful HIPAA compliance for your medical spa, practice, beauty salon, or GP

    1. Appoint a HIPAA compliance officer

    The first step in ensuring proper HIPAA compliance is appointing a compliance officer. 

    Typically, a compliance officer is any person or persons, that is:

    • A covered entity, like an employee at your medical spa, or a designated staffer who meets the requirements for the role.
    • A business associate who is actively collaborating with your medical spa. 

    The compliance officer will manage the HIPAA compliance process at all times, and:

       ✔️ Ensure all security and privacy policies are enforced
       ✔️ Manage privacy training for employees
       ✔️ Complete risk assessments
       ✔️ Develop security and privacy processes
       ✔️ Detect, and report on potential data breaches
       ✔️ Create a disaster recovery plan
       ✔️ Ensure the proper implementation of the HIPAA Security Rule

    Keep in mind — bigger-size medical spas may need more than one compliance offer for these tasks, or even assign a committee. They will be the first responders in preventing breaches and reducing the risks thereof.

    2. Develop security management policies and standards

    HIPAA compliance is all about documentation. As a healthcare practice, you need to develop and implement specific procedures and policies provided by HIPAA. This will ensure private, secure, and breach-free PHI management down the line. 

    Some of these policies may apply to access management, data backup, and retention, disaster recovery, or incident response. All policies and procedures that protect PHI will be continuously tracked and managed by your appointed HIPAA compliance officer.

    A compliance officer will also be tasked to create all reports and documentation needed to support your HIPAA compliance and highlight the main issues. 

    This documentation is mandatory for HIPAA compliance and includes these reports:

    📝 Evidence of HIPAA Compliance — maintains evidence and documentation for compliance tasks, like log-in files, patch analysis, and user/computer information.

    📝 Site diagram — organizes network assets using color-coded status and detailed information for easy access.

    📝 Windows Patch Assurance Report — assesses the client’s patch management program by using scan data to identify missing patches on the network. 

    📝  Full Detail Excel Export Report — overview your assessment, organized in an Excel worksheet for easy navigation, with issues highlighted in red for quick identification

    📝  HIPAA Privacy Rule Worksheet — evaluate the compliance of your site’s policies and procedures with HIPAA privacy standards.

    📝 HIPAA Breach Notification Worksheet — evaluate how well your site’s policies and procedures adhere to the HIPAA breach notification standards.

    📝 HIPAA Security Rule Auditor Checklist — determine if the client complies with HIPAA. 

    📝 HIPAA Compliance PowerPoint — a PowerPoint presentation for sharing  investigation findings, including a summary, risk scores, issue recommendations, and next steps.

    📝 HIPAA Management Plan — using the findings from the Risk Analysis, you need to develop a Risk Management Plan to address and prioritize the top risks.

    📝 HIPAA Policies & Procedures Sample Document — ensure that you are aligned with the HIPAA Security Rule, Privacy Rule, and Breach Notification Rule. This specifies what your organization will do and how — crucial for audits.

    📝 HIPAA Risk Analysis — a fundamental aspect of ensuring security that identifies ePHI locations, flaws, threats, and security measure access. 

    📝 Security Exception Worksheet —This report explains how security exceptions are managed for HIPAA compliance, with a section for specialists to clarify and address potential false alarms.

    Keeping records and documentation is essential for achieving HIPAA compliance for medical spas. This documentation will help you shield sensitive information and take the necessary risk prevention steps you outlined.

    3. Manage PHI access for business associates

    Sometimes, certain business associates will come into contact with your spa’s PHI, like Pabau’s software for example. And just like covered entities (your practice), business associates will be also obligated to protect the patient data they deal with.

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    As a covered entity, you will need to sign a legal business associate agreement (BAA) to ensure maximum PHI security. A BAA typically covers various security aspects, like:

    • PHI usage permissions
    • Reports on unauthorized PHI access and use
    • Processes on PHI termination

    4. Implement safeguards of the HIPAA Security Rule 

    To enable maximum PHI protection, the HIPAA Security Rule imposes three safeguards — administrative, physical, and technical.

    👉 Administrative safeguards help employees properly use and store PHI.
    You can implement it accordingly by training employees on how to protect PHI, resolve PHI threats, and handle PHI in case of emergencies.

    👉 Physical safeguards protect the physical points of access to PHI. They guide employees on how to manage their workstations and devices to provide optimal protection of sensitive information. An example of a physical safeguard can be limiting physical access to surveillance camera data, iPads, or ID badges.

    👉 Technical safeguards offer protection against unauthorized access to PHI or PHI changes stored across applications and systems. Antivirus software and data encryption are some technical safeguards you might need to consider. 

    5. Perform risk assessments

    The next step in ensuring proper HIPAA compliance for medical spas is to perform risk assessments. Risk assessments help you detect any flaws or gaps that may lead to data breaches, especially under the HIPAA Security Rule. 

    While risk assessments are mandatory, HIPAA does not share guidelines on how to do them, that’s up to you. 

    But as a rule of thumb, when assessing security risks, consider the following steps:

       ⬜ Determine where your PHI is stored and shared

       ⬜ Detect potential threats and liabilities related to PHI

       ⬜ Analyze how and if your existing security measures can help

       ⬜ Document any gaps, flaws, or potential risk factors

       ⬜ Determine the risk levels for each threat

       ⬜ Address the most likely and impactful security risks

       ⬜ Review and update risk analysis regularly

    6.  Train employees on HIPAA procedures

    HIPAA compliance training is mandatory for all staffers in your spa who handle PHI. Through training, your team members will be able to better understand how HIPAA compliance works, why it matters, and what non-compliance looks like.

    Although there is no precise guideline on how often you should enforce training, you can start doing it annually. Or, do it more periodically if you have new employees who need to get up to speed. For successful training, make sure employees are aware of all existing compliance policies and rules, violations, and emergency protocols.  

    7. Address threats immediately and improve

    Businesses need an average of 197 days to identify security threats, and 69 days to resolve them. This is a very long time to leave sensitive patient data out in the open. 

    In contrast, businesses that addressed and resolved a breach in less than 30 days, managed to save over $1 million. This puts the importance of prompt responses to threats into perspective.

    Whenever a breach occurs, your medical spa must conduct a thorough investigation to determine the underlying causes. Don’t hesitate to impose stronger controls when resolving threats, to prevent similar issues from happening again.

    Be safe, not sorry — learn more about HIPAA violations from the Department of Health & Human Services (HHS) so you can prevent issues before they even happen.

    8.  Regular monitoring and security policy updates

    Regularly monitoring compliance policies prevents costly HIPAA violations and enhances data protection. Some of the tools that help you monitor ongoing HIPAA compliance by enforcing:

       ⬜ Regular security audits

       ⬜ Automated policy checks

       ⬜ Employee training programs

       ⬜ Incident tracking and reporting

       ⬜ Encryption & access controls

    By regularly monitoring HIPAA compliance, you’ll boost data protection, ensure legal adherence, and minimize the risk of breaches. In turn, HIPAA compliance will build trust among patients, boost your practice efficiency, and protect you legally, and financially.

    Activate HIPAA compliance for medical spas with Pabau

    Have you already checked all the steps required for HIPAA compliance? 

    Perfect — time to activate HIPAA in Pabau. To save effort and prevent confusion, Pabau made it super-easy for practices, clinics, hair salons, and GPs to ensure HIPAA compliance. We’ve built several features that will support your HIPAA compliance and ensure the protection of your patients’ most sensitive data throughout their entire treatment at your medical spa. 

    Once you have gone through every step of your compliance, all you need to do is switch on the HIPAA toggle in your Pabau account settings and automatically run your compliance. That’s it!

    What you should do now

    1. Schedule a Demo to see how Pabau can help your team.
    2. Read more clinic management articles in our blog.
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