OCRs Latest HIPAA Guidance Strategic Measures to Protect Your Systems and Data Baker Donelson JDSupra

pppThe US Department of Health and Human Services HHS Office for Civil Rights OCR recently released its January 2026 Cybersecurity Newsletter focusing on system hardening and security baselines as critical components of the Health Insurance Portability and Accountability Act HIPAA Security Rule compliance The guidance reinforces OCRs continued expectation that HIPAA covered entities and business associates regulated entities proactively reduce cybersecurity risks to electronic protected health information ePHI through ongoing technical and operational safeguards OCR emphasizes that system hardening directly supports the HIPAA Security Rules core requirement to ensure the confidentiality integrity and availability of ePHI Privacy and security officers should also consider these recommendations as a baseline for risk management responsibilities and consider integrating the safeguards into internal auditing programsppOCR reiterates in the newsletter that unpatched vulnerabilities are a recurring root cause in HIPAA investigations To ensure appropriate patching has occurred regulated entities mustppBy way of example without a complete IT asset inventory an organization cannot be assured that complete patching has occurred on all systems OCR stresses that patching is continuous not episodic Newly discovered vulnerabilities whether in operating systems applications firmware or even prior patches must be reassessed through the HIPAA risk analysis and mitigated to a reasonable and appropriate levelppOCR acknowledges that patches may not always be available eg zeroday vulnerabilities or unsupported legacy systems However regulated entities are still expected to implement compensating controls such as disabling unnecessary services network segmentation access restrictions and enhanced monitoring The failure to patch must be paired with documented alternative safeguardsppOCR highlights enforcement findings involvingppEntities should not only remove unneeded software but also confirm that any associated user or service accounts are fully removed which OCR noted is a frequently overlooked vulnerabilityppOCR underscores the importance of configuring both native and thirdparty security measures specifically including the following expectationsppRisk analysis should drive decisions about which controls are necessary and where thirdparty solutions are required The documentation regarding the risk analysis should be robust enough to support changes and considerations for when tools or practices are not universally deployedppOCR points to widely used frameworks such as NIST SP 80053 Microsoft Security Baselines or Department of Defense Security Technical Implementation Guides While leveraging these resources can improve efficiency and consistency OCR cautions that checkbox adoption is insufficient Baselines must be reviewed understood and tailored to the entitys environment and documented through the HIPAA risk management processppBefore deploying system changes to production OCR advises testing in development or test environments to avoid unintended impacts on ePHI Additionally when environmental or operational changes affect security the HIPAA Security Rule requires documented technical and nontechnical evaluations to confirm continued complianceppIn light of OCRs guidance regulated entities should considerppOCRs newsletter aligns with enforcement trends showing increasing scrutiny of basic cybersecurity hygiene failures including unpatched systems default credentials and poor configuration management These issues are frequently cited in OCR resolution agreements and corrective action plans and therefore have a corresponding impact on the growing data breach classaction litigation System hardening is not merely a technical best practice it is a compliance obligation under the HIPAA Security Rule and a very clear risk management toolppSee more ppDISCLAIMER Because of the generality of this update the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations
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