Both the HIPAA Privacy Rule (45 CFR 164.530(i)) and Security Rule (45 CFR 164.316(a)) require covered entities and business associates to implement reasonable and appropriate policies and procedures to comply with HIPAA standards. These policies must be documented, maintained, and made available to workforce members.

6-Year Retention Requirement

HIPAA mandates that policies and procedures must be retained for 6 years from the date of creation or the date when the document was last in effect, whichever is later (45 CFR 164.530(j) and 164.316(b)(2)(i)).

Required Policy Areas

Privacy Rule Policies

  • Notice of Privacy Practices (NPP) — Description of PHI uses, disclosures, and individual rights
  • Uses & Disclosures Policy — Rules governing permitted and required uses/disclosures of PHI
  • Minimum Necessary Policy — Procedures to limit PHI access to the minimum necessary
  • Individual Rights Policy — Procedures for access, amendment, accounting, restriction requests
  • Authorisation Policy — Requirements for valid authorisations for non-routine disclosures
  • Sanctions Policy — Workforce discipline for HIPAA violations

Security Rule Policies

  • Risk Analysis & Risk Management Policy
  • Access Control Policy — User authentication, unique user IDs, emergency access, automatic logoff, encryption
  • Audit Control Policy — Procedures for recording and examining information system activity
  • Integrity Policy — Mechanisms to protect ePHI from improper alteration or destruction
  • Transmission Security Policy — Encryption and integrity controls for ePHI in transit
  • Workstation Use & Security Policy
  • Device & Media Controls Policy
  • Facility Access Control Policy
  • Security Incident Response Policy
  • Contingency Plan — Data backup, disaster recovery, and emergency mode operation plans
  • Business Associate Management Policy

Breach Notification Policies

  • Breach Notification Policy — Procedures for identifying, investigating, and reporting breaches
  • Breach Risk Assessment Policy — Four-factor risk assessment methodology

Policy Review Cycle

HIPAA requires policies to be reviewed and updated periodically and in response to environmental or operational changes (45 CFR 164.316(b)(2)(iii)). Best practice is to review all HIPAA policies at least annually. Venvera flags policies approaching or past their review date on the dashboard.