§164.530(b)(1) Standard: Training. A covered entity must train all members of its workforce on the policies and procedures with respect to protected health information required by this subpart and subpart D of this part, as necessary and appropriate for the members of the workforce to carry out their functions within the covered entity.
(2) Implementation specifications: Training. (i) A covered entity must provide training that meets the requirements of paragraph (b)(1) of this section, as follows: (A) To each member of the covered entity’s workforce by no later than the compliance date for the covered entity; (B) Thereafter, to each new member of the workforce within a reasonable period of time after the person joins the covered entity’s workforce; and (C) To each member of the covered entity’s workforce whose functions are affected by a material change in the policies or procedures required by this subpart or subpart D of this part, within a reasonable period of time after the material change becomes effective in accordance with paragraph (i) of this section. (ii) A covered entity must document that the training as described in paragraph (b)(2)(i) of this section has been provided, as required by paragraph (j) of this section.
Audit Inquiry
Does the covered entity train its work force and have policies and procedures to ensure all members of the workforce receive necessary and appropriate training in a timely manner as provided for by the established performance criterion?
Obtain and review such policies and procedures. Areas to review include training each new member of the workforce within a reasonable period of time and each member whose functions are affected by a material change in policies or procedures.
From the population of new hires within the audit period, obtain and review a sample of documentation of necessary and appropriate training on the HIPAA Privacy Rule that has been provided and completed.
Obtain and review documentation that workforce members have been trained on material changes to policies and procedures required by the HITECH Act.