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Free preview: HIPAA Security Management Policy — HIPAA Compliance Toolkit — Mental Health Practices

Read an excerpt from the HIPAA Compliance Toolkit — Mental Health Practices. The purchase includes 18 Word files and 2 Excel workbooks. The amber [placeholders] identify fields to customize. Review the wording, roles and schedules as well so they reflect how your organization operates.

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Inspect the mental-health risk-assessment sample

Open an editable excerpt from the mental-health edition’s Security Risk Assessment workbook. See how the worksheet records current measures, remediation and responsibility for a practice. No email or account required.

Download risk-assessment sample (.xlsx)

This sample contains the Risk Analysis and Risk Management rows with all 10 columns from the workbook. It records assessment and remediation decisions; it does not calculate risk scores. The full toolkit also includes the policy documents and Audit Evidence Checklist listed on the product page.

The full purchase includes 18 Word documents and 2 Excel workbooks.

Steps to try in your downloaded sample

Review the two sample rows and replace the practice and role placeholders with your own example details.
Try the “In place?” selection and edit the current measures, remediation, owner and target-date fields.
Save your copy and compare the workbook fields with the Security Management Policy excerpt below. Tailor the decisions and responsibilities to how your practice operates.

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Review applicability and tailor these policies to your organization. Review frequencies and internal deadlines in the excerpt are template choices, not universal HIPAA deadlines. HHS does not prescribe a particular risk-analysis workbook or methodology. Read HHS risk-analysis guidance.

HIPAA Security Management Policy

Purpose. This policy establishes the security management process by which [Practice Name] identifies, analyzes, and reduces risks to electronic protected health information (ePHI) created, received, maintained, or transmitted in the course of providing outpatient mental and behavioral health services. It implements the security management process standard at 45 CFR 164.308(a)(1), including risk analysis, risk management, sanctions, and information system activity review. It also names the accountable role responsible for the program and commits the practice to a documented, repeatable risk analysis.

Policy Statement

[Practice Name] must maintain a formal, documented security management process that protects the confidentiality, integrity, and availability of ePHI. Because the practice delivers mental and behavioral health care, the ePHI it holds includes diagnoses, session documentation, and psychotherapy notes whose disclosure could cause serious harm to clients, including stigma, employment consequences, and damage to the therapeutic relationship. The practice therefore treats security management as a clinical-quality obligation, not only a regulatory one.

The security management process consists of four required activities: (1) risk analysis, (2) risk management, (3) application of sanctions for security violations, and (4) information system activity review. Each activity must be performed on the schedule defined in this policy, assigned to a named responsible role, and documented in a form that can be produced during an audit, an OCR investigation, or a breach assessment.

Accountability and the Security Official

The owner or managing partner of [Practice Name] must designate, in writing, a Security Official who is accountable for developing and implementing the security policies and procedures of the practice. The designation, qualifications, authority, and time allocation for this role are defined in Security Official Designation and Responsibilities, which is a companion to this policy.

The Security Official must report on the status of the security management program to [Practice Owner / Managing Partner] at least [quarterly], and immediately upon discovery of any high-risk finding or suspected security incident.

Risk Analysis

The Security Official must conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of all ePHI held by [Practice Name]. The risk analysis must be completed at least [annually] and additionally whenever the practice adopts a new teletherapy platform, EHR, scheduling or messaging application, opens or closes an office location, begins or ends a supervision or internship program, or experiences a security incident that exposes a previously unknown weakness.

Risk Management

The Security Official must implement security measures sufficient to reduce identified risks and vulnerabilities to a reasonable and appropriate level, taking into account the size and resources of the practice, its technical infrastructure, the cost of measures, and the probability and criticality of potential risks to ePHI. Every risk rated Moderate or higher must have a documented treatment decision: remediate, mitigate with compensating controls, or accept with written justification approved by [Practice Owner / Managing Partner].

The Security Official must maintain a risk register listing each identified risk, its rating, the treatment decision, the responsible person, and the target completion date, and must update the register at least [quarterly].

— End of the excerpt. See the product page for the full list of included files. —

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