hipaa-compliance-checker

name	hipaa-compliance-checker
description	Evaluates systems, workflows, and data handling practices against HIPAA Privacy and Security Rules. Outputs a compliance gap analysis with risk-rated findings, remediation steps, and required documentation checklist.
allowed-tools	Read, Write
effort	high

HIPAA Compliance Checker

When to activate

When designing any system that handles PHI, before onboarding a new vendor (BAA review), during annual compliance assessments, or when an incident occurs. Use for software systems, data pipelines, telehealth platforms, and analytics environments.

When NOT to use

Skip for systems that only handle de-identified data (verified via Safe Harbor or Expert Determination method), publicly available health statistics, or when a full compliance audit was completed within the last 90 days on the same system.

Instructions

1. Scope determination:

   • What PHI is collected, stored, transmitted, or displayed?
   • Which systems, databases, and applications touch PHI?
   • Who has access (roles, not individuals)?
   • Are all Business Associate Agreements (BAAs) in place?

2. Privacy Rule assessment:

   • Minimum necessary: Is PHI access limited to what's needed?
   • Patient rights: Access, amendment, accounting of disclosures
   • Notice of Privacy Practices (NPP) current and distributed?
   • Authorization requirements: Treatment, payment, operations vs. other uses

3. Security Rule assessment:

   • Administrative: Risk analysis, workforce training, incident response plan
   • Physical: Facility access, workstation security, device disposal
   • Technical: Access controls, audit logs, encryption (at rest + in transit), integrity controls

4. Risk rating for each finding:

   • CRITICAL: Active breach risk, immediate remediation required
   • HIGH: Significant gap, remediate within 30 days
   • MEDIUM: Moderate gap, remediate within 90 days
   • LOW: Minor improvement, address in next review cycle

Output Format

HIPAA COMPLIANCE ASSESSMENT: [System/Workflow name]
DATE: [date] | ASSESSOR: [name]
SCOPE: [PHI types, systems, user roles]

BAAs: [All in place / Missing: list]

FINDINGS:
| # | Category | Finding | Risk | Remediation | Due Date |
|---|----------|---------|------|-------------|----------|

SUMMARY:
  Critical: [X] | High: [X] | Medium: [X] | Low: [X]
  Overall risk: [Critical/High/Medium/Low]

REQUIRED DOCUMENTATION:
  - [ ] Risk analysis (annual)
  - [ ] Policies and procedures (updated)
  - [ ] Workforce training records
  - [ ] Incident response plan (tested)
  - [ ] BAAs (executed, current)
  - [ ] Audit log review (quarterly)

Example

HIPAA COMPLIANCE ASSESSMENT: Patient Portal v3.0
DATE: 2026-06-13 | ASSESSOR: Compliance Team
SCOPE: Demographics, lab results, medications, visit notes | PostgreSQL + React frontend | Patient + clinician roles

BAAs: Missing — cloud hosting provider (AWS) BAA not executed

FINDINGS:
| # | Category     | Finding                              | Risk     | Remediation                          | Due Date |
|---|--------------|--------------------------------------|----------|--------------------------------------|----------|
| 1 | Technical    | No encryption at rest on PostgreSQL  | CRITICAL | Enable AES-256 encryption            | 2026-06-28 |
| 2 | Admin        | BAA missing for AWS hosting          | HIGH     | Execute BAA with AWS                 | 2026-07-13 |
| 3 | Technical    | Audit logs retained only 30 days     | MEDIUM   | Extend to 6 years per state law      | 2026-09-13 |
| 4 | Privacy      | NPP not updated since 2023           | LOW      | Review and update NPP                | 2026-12-13 |

SUMMARY:
  Critical: 1 | High: 1 | Medium: 1 | Low: 1
  Overall risk: Critical — unencrypted PHI at rest

REQUIRED DOCUMENTATION:
  - [x] Risk analysis (annual) — completed 2026-03
  - [ ] Policies and procedures — needs update for v3.0
  - [ ] Workforce training records — 3 staff overdue
  - [ ] Incident response plan — last test: 2025-08 (overdue)
  - [ ] BAAs — AWS BAA pending
  - [ ] Audit log review — Q2 review not started