Compliance Review Program
The California Office of Health Information Integrity (CalOHII) has statutory responsibility to evaluate, monitor, and report on state departments’ HIPAA compliance. The goals of CalOHII’s Compliance Review Program are to:
- Create a collaborative culture of compliance for state departments
- Keep Californian’s health information safe
- Provide technical assistance and leadership on California’s HIPAA compliance
This page provides state departments (subject to HIPAA) with general information about the Compliance Review Program:
- What is a Compliance Review?
- Who is Subject to a Compliance Review?
- What Happens during a Compliance Review?
- Tips and Tools & How to Prepare for a Compliance Review?
What is a Compliance Review?
The Compliance Review Program is responsible for conducting ongoing compliance reviews on state departments subject to HIPAA. The Compliance Review team’s focus during the compliance review is to work with the state department to identify any gaps in HIPAA compliance (based on the Statewide Health Information Policy Manual) and monitor the resolution of all identified compliance gaps.
Who is Subject to a Compliance Review?
State departments assessed to be covered entities and/or business associates are subject to compliance reviews. For a list of the state departments subject to HIPAA and/or more information about the most recent assessment, refer to the 2017 HIPAA Entity Status Assessment page.
What Happens during a Compliance Review?
State departments are notified several weeks before they are scheduled for a compliance review – see CalOHII Compliance Review Schedule for the anticipated timing of upcoming compliance reviews.
The compliance review begins with the department providing the Compliance Review team with artifacts/documents (see the Compliance Review Artifact Request List) and answering compliance questions (see the Compliance Review Tool) within a specified time frame. The team reviews all materials collected from the department (see the Compliance Review Artifacts Checklists) to document initial observations.
After the materials are reviewed, an onsite review is scheduled with the department. During the onsite visit, the CalOHII Compliance Review team conducts follow-up meetings to clarify information received from the department and tours selected operational areas of the department.
All observations and findings are documented along with recommendations for addressing gaps. A draft document is provided to the department for review and comments before CalOHII finalizes the report.
Once the report is finalized, the review moves into the Corrective Action Plan phase. During this time, CalOHII works with the department to track and monitor the resolution of all gaps identified (see Corrective Active Plan Template).
Tips and Tools & How to Prepare for a Compliance Review?
CalOHII provides the following documents to assist departments prepare for a compliance review.
- Compliance Review Artifact Request List
- Compliance Review Tool
- Compliance Review Artifacts Checklists
- Corrective Action Plan Template
- Tips and Tools: Risk Analysis/Assessment
- Tips and Tools: Policy and Procedures
- OCR Audit Protocol
If you have any questions, contact Virginia Franco-Varela at Virginia.Franco@chhs.ca.gov