HCCP Compliance Strategy

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• Perform a formal HIPAA-compliant Security Risk Analysis in      accordance with 45 CFR §164.308(a)(1)(ii)(A)
• Identify administrative, technical, and physical safeguard gaps
• Establish a compliance baseline across documentation, access controls, and data protection

• Evaluate organizational readiness for Medicare certification and federal audit scrutiny
• Review policy library, workforce training, BAAs, and breach protocols
• Assess MSP or IT alignment with NIST Cybersecurity Framework (CSF) and HIPAA technical standards

• Internal and external system vulnerability review
• Identify outdated systems, unsecured access points, and PHI exposure risks
• Optional credential exposure and email breach risk check

• External Penetration Test:
  Identify vulnerabilities exposed to the public internet, including unpatched systems, insecure portals, and misconfigured servers
  Simulate real-world cyberattacks targeting patient data, credentials, or network entry points
   
• Internal Penetration Test:
  Evaluate internal network security, including access controls, lateral movement risk, and endpoint weaknesses

• Detect vulnerabilities within staff devices, medical systems, local servers, and wireless networks
   
• HIPAA Alignment:
  Testing fulfills HIPAA’s required ongoing evaluation of system vulnerabilities (§164.308(a)(8))
  Supports audit readiness and breach risk reduction under CMS and HHS guidance
   
• Deliverables Include:
  Detailed Penetration Testing Report
  Executive Summary & Risk Rating
  Exploitation and Attack Vector Findings
  Remediation Recommendations

HCCP provides a complete documentation and operational compliance package designed to help hospice providers demonstrate readiness to Medicare auditors, regulators, and oversight bodies.

Deliverables include:

• Comprehensive Compliance Findings Report
  A detailed analysis of administrative, technical, and physical safeguard gaps based on the HIPAA Security Rule, HITECH, CMS certification standards, and NIST CSF alignment. Includes prioritized risk ratings.
• Plan of Action & Milestones (POA&M)
  A formal, regulator-facing remediation roadmap outlining required corrective actions, assigned responsibilities, and remediation timelines—used to satisfy HHS/OCR and CMS audit expectations.
• Medicare Compliance Roadmap
  A clear visual and operational timeline showing certification steps, audit preparation stages, and milestone checkpoints for provider executives and compliance teams.
• Customized Policy & Procedure Library
  HIPAA- and CMS-compliant policies and procedures tailored to the provider’s environment. Includes Privacy Rule, Security Rule, Breach Notification, Workforce Sanctions, Access Control, Device Security, and more.
• Security Risk Analysis (SRA) Documentation Package
  Includes formal SRA report, risk methodology, asset inventory, risk register, control mapping, and recommendations—satisfying CMS, OCR, and Promoting Interoperability requirements.
• Penetration Testing Reports
  Internal and external penetration test findings, with threat vector summaries, risk categorizations, and actionable remediation plans. Supports HIPAA §164.308(a)(8) compliance.
• Audit Response Toolkit
  Includes an evidence binder outline, document map, regulatory traceability matrix, and interview prep materials for TPE, MAC, UPIC, and OCR audits.
• Executive & Staff Briefing Decks
  Targeted training materials and briefing presentations designed to educate internal leadership and staff on audit procedures, CMS expectations, and compliance roles.
• Risk Governance Dashboard
  High-level reporting for executives and boards, summarizing the current compliance posture, audit risks, and mitigation progress.
• Optional: Digital Documentation Repository
  A secure, structured folder system for storing and managing all compliance artifacts—ready to present during an audit or investigation.

Closing compliance gaps, hardening safeguards, and building audit-proof operations

HCCP works directly with hospice provider leadership, compliance officers, and IT or Managed Service Providers (MSPs) to operationalize compliance—not just on paper, but in practice.

Our remediation and readiness services include:

• Policy Remediation & Development
  Draft, revise, or replace outdated or incomplete HIPAA, privacy, and CMS-required policies. Ensure alignment with the HIPAA Security Rule, HITECH, 42 CFR Part 2, and CMS Conditions of Participation.
   
• Procedural Integration
  Assist in implementing procedures for incident response, breach notification, access control, data backup, contingency operations, device/media management, and sanction enforcement.
   
• Documentation Control & Structuring
  Organize and label compliance documentation using a standardized audit format. Create a secure document repository indexed to regulatory requirements and evidence binders.
   
• Corrective Action Support
  Guide the development of Corrective Action Plans (CAPs) in response to internal findings or external audit notices. Includes remediation workflows and oversight tracking.
   
• Workforce Training & Role-Based Briefings
  Deliver targeted compliance education, annual HIPAA training, and executive briefings. Prepare leadership for regulatory interviews and audit responses.
   
• Internal Testing & Mock Audits
  Conduct tabletop exercises and mock audit sessions to test documentation readiness, staff preparedness, and leadership response. Identify residual risks before real auditors arrive.
   
• Governance & Executive Communication
  Equip senior management with reporting dashboards, compliance calendars, risk maps, and executive summaries to track status, assign accountability, and maintain ongoing visibility.
   
• Technical Hardening Collaboration
  Coordinate with internal IT or external MSPs to implement security improvements (firewalls, endpoint protection, access controls, logging, patching, etc.) necessary for HIPAA and NIST alignment.
   
• Managed Audit Readiness Timeline
  Establish a compliance calendar and progress tracking dashboard aligned to federal reporting cycles, state inspections, and Medicare revalidation events.
   

Turn audits into controlled, evidence-driven exercises—never emergencies.

The HCCP Audit Defense Toolkit is designed to equip hospice providers with the structured documentation, response protocols, and internal readiness necessary to navigate any regulatory audit, probe, or investigation with confidence and clarity.

Toolkit Components:

• Regulatory Traceability Matrix
  Maps each policy, control, and training artifact to its corresponding CMS, HIPAA, HITECH, or NIST requirement—ensuring nothing is missed and every standard is traceable to a defensible document or control.
   
• Audit Evidence Binder Template
  A ready-to-deploy organizational framework for categorizing, labeling, and presenting compliance evidence. Includes tabs for HIPAA Privacy, HIPAA Security, SRA documentation, workforce training logs, access controls, device policies, breach response plans, and risk remediation.
   
• Audit Notification & Intake Protocols
  SOPs for responding to CMS TPE letters, UPIC probes, OCR investigations, or HHS Office of Inspector General (OIG) audits. Includes contact roles, evidence timelines, and communication language templates.
   
• Audit Interview Prep Guide
  Role-specific briefing decks for executives, compliance officers, IT/MSP leads, and frontline staff—covering anticipated audit questions, appropriate responses, and “do/don’t say” language. Includes mock interview walkthroughs.
   
• Incident & Breach Documentation Templates
  Pre-formatted logs and attestation forms for documenting incidents and demonstrating breach response activities required under HIPAA §164.308(a)(6) and §164.404.
   
• Corrective Action Plan (CAP) Framework
  Template to document and submit CAPs in response to findings, with structured narrative, accountable parties, remediation timelines, and implementation tracking per HHS and CMS standards.
   
• Executive Command Briefs
  Condensed situational reports for executive leadership that summarize audit scope, response readiness, open risks, and decision points—designed for board briefings or legal counsel coordination.
   
• Regulatory Communication Log
  A standardized log to document communications with CMS auditors, MAC representatives, or OCR personnel, tracking dates, requests, responses, and evidence provided—preserving a full chain of custody.
   
• Real-Time Advisory Support
  (Optional add-on) Real-time, on-call support during the audit window to help coordinate responses, prepare documents, and brief leadership. Includes response QA and review of all outgoing communications.
   

Audits are not just requests—they’re legal inquiries with funding, licensing, and reputation on the line. HCCP gives hospice providers the tools to respond with confidence, show full compliance posture, and preserve operational stability throughout the audit process.

Ongoing compliance is not a phase—it’s a discipline.

At HCCP, we believe compliance is not a one-time event. Sustaining Medicare eligibility and audit defensibility requires a living compliance program—monitored, updated, and reinforced as threats, regulations, and organizational changes evolve.

Our Sustainment & Compliance Maturity Program provides continuous support and risk visibility for hospice providers across all operational tiers.

Key Sustainment Services Include:

• Annual Security Risk Analysis (SRA) Renewal
  Perform required yearly SRA to remain HIPAA-compliant, maintain Medicare certification, and satisfy Promoting Interoperability (formerly Meaningful Use) program criteria.
• Quarterly Compliance Reviews
  Proactive evaluations of compliance controls, documentation, training logs, and risk mitigation progress. Identify drift, new exposures, and unaddressed vulnerabilities.
• Policy & Procedure Lifecycle Management
  Ensure all privacy and security policies are reviewed, updated, and re-approved annually or upon regulatory change. Archive superseded versions with full version control.
• Continuous Training & Certification Tracking
  Maintain HIPAA training schedules, track workforce compliance, and ensure new hires are onboarded with required documentation. Includes tracking for clinical and non-clinical personnel.
• Audit Simulation & Tabletop Exercises
  Conduct regular audit readiness drills to maintain confidence, improve response times, and strengthen your team’s ability to demonstrate documentation under pressure.
• Breach & Incident Response Readiness Checks
  Rehearse privacy breach notification and security incident reporting procedures per HIPAA §164.308(a)(6), ensuring rapid containment, notification, and audit log review.
• Executive Dashboards & Compliance Scorecards
  Provide leadership with regular reports that track audit preparedness, staff training status, policy updates, SRA progress, and open corrective actions.
• CMS Regulation Watch & Advisory Alerts
  Receive proactive alerts when CMS, HHS, or OCR announce regulatory updates, enforcement actions, or new compliance requirements—curated by our advisory team.
• vCISO & Strategic Oversight (Optional)
  Access ongoing advisory services from a virtual Chief Information Security Officer (vCISO) to monitor governance, participate in board discussions, and support provider maturity goals.

HCCP empowers hospice providers to pass Medicare audits, secure federal reimbursement, and operate with confidence in a rapidly intensifying regulatory landscape.

Through a structured, evidence-based compliance lifecycle, providers benefit from:

✅ Audit-Ready Documentation — Every policy, procedure, SRA, and training artifact is aligned to CMS, HIPAA, and HHS standards and prepared for immediate regulatory scrutiny.
 

✅ Defensible Compliance Posture — From OCR audits to MAC probes, clients can prove—with documentation—compliance across privacy, security, breach response, and training.
 

✅ Sustained Medicare & Medicaid Eligibility — Certification safeguards reimbursement, licensing, and operational continuity for providers serving high-need populations.
 

✅ Risk Reduction & Breach Resilience — Technical testing and governance improvements reduce exposure to cyberattacks, human error, and fines for non-compliance.
 

✅ Internal Accountability & Executive Oversight — Governance dashboards and briefings support CFOs, CIOs, COOs, and Compliance Officers in tracking risk, gaps, and outcomes.
 

✅ Stronger Brand & Regulatory Trust — A verified, repeatable compliance program increases credibility with regulators, payers, and referral partners.
 

Bottom Line: HCCP transforms compliance from a liability into a strategic advantage—preserving funding, reducing risk, and ensuring your organization is built to withstand scrutiny.