10 SOC 2 Audit Mistakes Healthcare Providers Make

SOC 2 compliance is critical for healthcare providers handling sensitive patient data. Yet, many organizations struggle with audits due to common pitfalls. Here's what you need to know:

• Underestimating Resources: SOC 2 audits demand time, effort, and cross-departmental coordination.
• No Project Manager: Without a dedicated leader, audits can spiral into disorganization.
• Skipping Readiness Assessments: Failing to identify gaps early leads to costly fixes later.
• Irregular Control Testing: Continuous monitoring is key to spotting and fixing issues before audits.
• Poor Documentation: Incomplete records make it hard for auditors to verify compliance.
• Outdated Systems: Legacy technology introduces vulnerabilities and compliance challenges.
• Lack of Staff Training: Employees must know how to handle sensitive data securely.
• Weak Communication: Siloed departments lead to missed details and inefficiencies.
• Uncoordinated Compliance: Aligning SOC 2 with HIPAA reduces redundant work.
• Manual Processes: Automated tools streamline risk management and reporting.

Avoiding these mistakes not only ensures audit success but also strengthens data security and patient trust. Let’s dive into the details of each issue and how to tackle them effectively.

A Complete Guide on [SOC2 Audit Process]

1. Not Allocating Enough Time and Resources

Healthcare providers sometimes underestimate just how demanding a SOC 2 audit can be. Many treat it as a side project, but achieving compliance requires a focused, cross-departmental effort and significant resources.

Aligning with the Trust Services Criteria is no small task. It involves overhauling documentation, monitoring processes, and security controls across all five criteria ^[3]. Without proper planning from the start, organizations often find themselves scrambling to meet deadlines, which can lead to serious problems.

Rushing through preparation usually results in incomplete controls, poorly documented processes, and, ultimately, audit failure ^[4]. For healthcare providers, these failures can erode trust, invite regulatory scrutiny, and lead to steep financial penalties ^[6].

When time and resources are poorly allocated, staff can become overwhelmed, increasing the risk of errors in managing Protected Health Information (PHI) ^[3]. To avoid this, it’s crucial to conduct a thorough gap analysis, set realistic timelines with built-in buffers, and assign a dedicated compliance officer or team to oversee the process ^[3].

Putting in the effort and resources upfront not only strengthens security but also helps prevent costly issues down the line ^[5]. If needed, bring in external experts to guide the process ^[3]. Proper planning and investment now lay the groundwork for avoiding the other audit challenges that will be discussed next.

2. Not Assigning a Project Manager

A SOC 2 audit is no small task - it involves multiple departments, piles of documentation, and tight deadlines. Without someone specifically in charge of managing the process, things can quickly spiral into chaos.

Many healthcare providers mistakenly assume that SOC 2 compliance will naturally fit into their day-to-day operations. This assumption often leads to missed deadlines, incomplete paperwork, and staff confusion about their roles. Assigning a dedicated project manager helps connect the dots between departments and ensures the audit runs more smoothly.

The reality is that a SOC 2 audit requires input from various areas like IT, legal, HR, and clinical operations. Without clear coordination, it’s easy for important details to fall through the cracks.

"This person will help drive the SOC 2 effort and manage the day-to-day responsibilities of gathering information, scheduling resources, etc. Your project manager doesn't necessarily need to fully understand the requirements for SOC 2 certification or have compliance expertise, but they need to be good at getting tasks completed across the organization."

• Brian Johnson, Security Engineer / Podcaster, StrongDM ^[7]

Having a project manager in place makes the entire process more organized and efficient ^[8].

An effective SOC 2 project manager should excel at communication, be highly organized, and know how to coordinate across departments. Their role involves keeping teams motivated, ensuring deadlines are met, and holding everyone accountable for their responsibilities. While they don’t need to be a compliance expert, they should be comfortable using project management tools and asking the right questions to keep the process on track ^{[7] [9] [10]}.

If your organization lacks internal project management expertise, consider hiring an external project manager ^[8]. This investment can lead to faster results, better organization, and less stress for everyone involved. A dedicated project manager doesn’t just streamline the audit - they also strengthen overall compliance efforts, which is critical for healthcare providers aiming for SOC 2 success.

3. Skipping Pre-Audit Assessments

Skipping a SOC 2 readiness assessment is like walking into a final exam without studying. Unfortunately, many healthcare providers make this mistake, only to uncover critical gaps in their controls and documentation when it’s too late to fix them effectively.

A readiness assessment acts as a trial run, highlighting weaknesses in your documents, policies, processes, and overall security setup ^[11]. Think of it as a diagnostic tool that not only identifies vulnerabilities but also helps you address overlapping healthcare regulations. The goal is simple: spot and fix security issues early to ensure you meet SOC 2 compliance standards. Tackling these gaps ahead of time not only boosts your audit readiness but also strengthens your overall compliance efforts.

Healthcare providers often need to align both HIPAA and SOC 2 requirements ^[13]. A readiness assessment can help clarify how these frameworks overlap and where conflicts might arise, making it easier to streamline compliance efforts.

During this assessment, an independent auditor reviews your systems, processes, and controls. They’ll document the key procedures that will come under scrutiny during the actual audit ^[14]. This process includes mapping your existing controls to the relevant Trust Services Criteria, identifying any gaps, and helping you create a remediation plan ^[12].

The cost for a professional SOC 2 readiness assessment typically ranges from $10,000 to $17,000, depending on your organization’s size and the audit’s scope ^[12]. While this might seem like a hefty investment, it’s far more affordable than dealing with the fallout of a failed audit or having to repeat the process due to poor preparation.

To make the assessment process smoother, gather key documents ahead of time. These might include asset inventories, change management records, equipment maintenance logs, system backup logs, codes of conduct, ethics policies, and business continuity and incident response plans ^[13].

Once gaps are identified, prioritize performing a gap analysis and schedule the readiness assessment well in advance of your SOC 2 audit ^[14].

Beyond just preparing you for the audit, a readiness assessment offers valuable insights into your security posture and helps build a stronger security culture ^[11]. For healthcare providers handling sensitive patient data, having this comprehensive understanding is absolutely critical.

4. Not Testing Controls Regularly

Too often, healthcare providers treat SOC 2 compliance as a once-a-year task, overlooking the importance of continuous monitoring. This mindset can lead to blind spots where control failures go unnoticed, putting sensitive patient data at risk. Regular monitoring helps close these gaps, ensuring potential issues are caught before they escalate.

For instance, a routine software update might inadvertently disable a security feature, an employee could misconfigure a system, or a new process might create unexpected vulnerabilities. Without consistent testing, these problems might only come to light during an audit - by which time, the damage could already be done.

The solution? Automation and a year-round approach. Set up a regular testing schedule that integrates control monitoring into your daily operations. This can include frequent internal audits, periodic system reviews, and automated tools to flag anomalies as they happen. These tools not only enhance visibility but also provide real-time alerts, enabling immediate action when something goes wrong ^[17][18].

Healthcare organizations should also prioritize annual penetration tests - or conduct them more frequently if audit cycles demand it - to ensure ongoing compliance ^[16]. Automated monitoring tools can further simplify the auditing process by continuously logging activities across your cloud environment, offering a clear view of your security posture at all times ^[18]. This real-time oversight is invaluable for catching issues early and addressing them promptly ^[17].

Regular testing does more than just protect data. It can uncover outdated accounts, enforce proper offboarding protocols, and highlight unnecessary privileged access ^[19].

"Continuous monitoring of controls is imperative not only from an organizational and risk standpoint but also to ensure your next audit report has as few exceptions/deviations as possible. If a company actively monitors controls and their operating effectiveness, they have a better chance of coming out of the next audit with a clean SOC report." - IS Partners Experts ^[15]

Investing in regular testing isn’t just about passing audits. It’s a proactive way to spot vulnerabilities before they turn into costly security breaches. More importantly, it builds trust with patients, showing them their data is handled with care and diligence ^[15]. By weaving control testing into everyday workflows, organizations can foster a security-first mindset that benefits everyone ^[17].

5. Poor Documentation and Record Keeping

For many healthcare providers, documentation often takes a backseat. But neglecting it can seriously derail audit success. Why? Because incomplete or unclear records make it nearly impossible for auditors to verify that your controls are functioning as intended. In healthcare, where documentation directly impacts reimbursement and compliance, the risks are even more pronounced. Missing or sloppy records can lead to compliance issues and hefty financial penalties.

As Dr. Joe puts it, "If the chart doesn't match the CPT code, payers will flag it. Documentation drives reimbursement and compliance." ^[21] The same logic applies to cybersecurity. If your security controls aren’t properly documented, you simply can’t prove they’re working during an audit.

This lack of documentation creates a blind spot for auditors, making it hard to confirm that your organization is following its own policies and procedures. Even the best security practices can become irrelevant if there’s no proof they’re being followed. And with the average data breach costing around $4.45 million in 2023, poor documentation can indirectly lead to significant financial losses ^[20].

The solution? Make documentation a core part of your daily security operations. Use templates to standardize records, schedule regular reviews, and assign clear responsibilities for updates. By treating documentation as an integral part of your workflow - not just a compliance box to check - you’ll see a noticeable improvement in both quality and completeness. This proactive approach is especially crucial as compliance requirements and security threats continue to evolve. Strong documentation forms the backbone of SOC 2 compliance, supporting the controls and processes established earlier in the audit process.

Healthcare organizations, in particular, need to stay ahead of constantly shifting security threats and regulatory demands. Regularly updating policies, procedures, and registers ensures your documentation stays relevant and effective ^[20]. Outdated or incomplete records can undermine audit results and leave your organization vulnerable.

6. Ignoring Old Systems and Technical Problems

Legacy systems are a major stumbling block when it comes to achieving SOC 2 compliance in healthcare. These outdated systems often lack the advanced security features required to meet today’s rigorous audit standards. Shockingly, 73% of healthcare providers are still reliant on these older systems ^[24]. The risks go far beyond aging hardware - they create critical operational vulnerabilities.

One of the biggest issues is the absence of essential updates. Legacy systems frequently run on unsupported operating systems and miss crucial security patches, leaving them exposed to breaches ^[25]. They also lack features like audit trails and role-based access controls, which are now standard requirements for compliance ^[25].

The financial burden of outdated technology is equally alarming. U.S. hospitals lose an average of $52,000 per physician annually due to reduced productivity, while operational efficiency drops by 20% over a five-year period ^[23][24]. This is especially concerning when you consider that a single breach involving protected health information (PHI) costs the healthcare industry an average of $10.93 million ^[26]. Ignoring technical debt doesn’t just drain resources - it creates vulnerabilities that could lead to catastrophic breaches.

A real-world example demonstrates the severity of this issue. In 2016, Banner Health suffered a breach caused by unpatched vulnerabilities in outdated software. The result? The personal information of approximately 3 million patients was exposed, leading to settlement costs of around $88 million ^[23]. This case highlights how technical debt isn’t just an IT headache - it’s a business-critical issue that directly affects SOC 2 compliance.

"Cybersecurity technical debt is a hidden but significant threat to organizations in the digital age... By understanding how cybersecurity technical debt accumulates and implementing strategies to manage it, organizations can safeguard their systems, protect their data, and maintain the trust of their stakeholders." – Nicola DeBlasi, Chief Strategy Officer at MPS Monitor and Nexera ^[22]

Budget constraints make addressing these problems even harder. According to Gartner, up to 75% of hospital IT budgets are consumed by maintaining legacy systems ^[26]. This leaves little room for the security upgrades needed to meet SOC 2 standards. However, there are ways to mitigate these risks within existing constraints.

Start by implementing compensating controls like encrypting sensitive data and improving access control measures in legacy systems ^[17]. Deploying data loss prevention (DLP) tools can help protect sensitive information, while identity and access management (IAM) solutions strengthen authentication and authorization ^[17]. Network segmentation can isolate legacy systems to prevent the spread of security incidents, and data masking can safeguard sensitive information in non-production environments ^[17].

Addressing technical debt should be an ongoing effort. Conduct regular security audits to identify vulnerabilities and outdated components, and establish a formal patch management process to ensure timely updates ^[22]. With ransomware attacks on hospitals increasing by over 90% from 2021 to 2024 ^[25], tackling legacy system weaknesses isn’t just about compliance - it’s about safeguarding your patients and securing the future of your organization.

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7. Lack of Staff Training and Knowledge

Employees are your first line of defense against security breaches, which makes ongoing training a must for passing a SOC 2 audit. In healthcare, where mistakes can have serious consequences, regular staff training becomes even more crucial ^[17]. And it’s not just the IT team that needs to be in the know - every single employee plays a part in protecting sensitive data. This shared responsibility is at the heart of maintaining data security ^[27].

Too often, healthcare organizations believe that a one-time training session is enough. But SOC 2 audits require more than that. They call for continuous education programs that adapt to new threats and evolving regulations ^[17]. Any gaps in training are glaring red flags during an audit. These gaps are especially risky in healthcare, where staff must know how to handle Protected Health Information (PHI) securely. That means understanding proper password management, spotting phishing attempts, and knowing how to report suspicious activity effectively.

To stay compliant, it’s important to maintain clear and updated training records. These should include details on completion and comprehension, and they should be refreshed annually, as well as for new hires or whenever policies change ^[27].

Make training engaging and practical. Use tools like videos, quizzes, and real-world scenarios to teach security awareness, policy compliance, and technical protocols. To streamline efforts, integrate SOC 2 compliance training into your existing HIPAA Security Rule programs. This approach can help address threats like malware, social engineering, and incident reporting in a more comprehensive way ^{[27] [28]}.

Failing to provide adequate training doesn’t just risk breaches - it can lead to fines and long-term damage to your organization’s reputation ^[29]. By setting high training standards and monitoring them consistently, you can reduce these risks significantly. Regular, effective training not only ensures compliance but also prepares your organization for the next hurdle: improving interdepartmental communication.

8. Poor Communication Between Departments

Achieving SOC 2 compliance in healthcare is not just an IT concern - it demands collaboration across all departments. When communication breaks down between siloed teams, critical information can slip through the cracks. For instance, security teams might roll out new controls without notifying compliance staff, leaving gaps in documentation. Similarly, if HR updates employee access procedures but fails to inform IT, it could unintentionally create vulnerabilities.

These communication gaps often show up in ways that are hard to miss: inconsistent documentation, duplicate efforts, and unclear roles that slow down responses to auditors ^[30]. Imagine a scenario where IT implements a new security measure but doesn’t inform the compliance team. Even if the control works perfectly, the lack of proper documentation or testing records could lead auditors to flag it as insufficient, putting your certification at risk ^[30].

SOC 2 compliance intersects with other critical areas like HIPAA, clinical operations, and patient safety, making clear communication even more essential. Departments such as nursing and billing need to understand how security updates might impact patient care workflows or their daily responsibilities.

To tackle these challenges, leadership must take an active role in fostering collaboration. When executives emphasize the importance of compliance and hold teams accountable for working together, departments are more likely to share information openly. This reinforces the idea that SOC 2 compliance is a shared responsibility.

There are practical steps to improve interdepartmental collaboration. Regular cross-departmental meetings focused on SOC 2 progress can help keep everyone aligned. Shared documentation repositories for policies and audit timelines ensure that the latest information is accessible to all. Additionally, appointing clear points of contact for questions or updates can prevent confusion.

Technology can also play a key role. Automated risk management platforms, like Censinet RiskOps™, provide centralized spaces for tracking risk assessments, documentation, and tasks. Tools like these help break down silos, making teamwork smoother and more effective.

The impact of poor communication goes beyond just failing an audit. It can lead to higher remediation costs, damage your organization’s reputation, and even result in non-compliance with other healthcare regulations. These outcomes can erode trust with patients and partners while exposing your organization to financial penalties ^[31].

Finally, it’s important to measure how well your communication strategies are working. Keep an eye on metrics like how quickly teams respond to auditor requests, how often cross-departmental meetings occur, and the completion rates of compliance tasks. These indicators can help ensure your efforts are on the right track.

9. Not Coordinating Multiple Compliance Requirements

Healthcare providers often tackle each compliance framework in isolation, which can lead to duplicated work, conflicting requirements, and wasted time. However, many regulatory frameworks share common elements. By aligning efforts, organizations can significantly reduce their compliance workload.

Take SOC 2 and HIPAA as an example. These frameworks overlap more than most organizations realize. Both focus on safeguarding sensitive data, implementing strong access controls, and maintaining detailed documentation. In fact, SOC 2’s Trust Services Criteria closely align with HIPAA's Security Rule, particularly in areas like administrative, physical, and technical safeguards ^[2]. Designing SOC 2 controls to also meet HIPAA requirements can simplify the process and save resources.

"Healthcare organizations that have implemented policies and procedures to comply with HIPAA should have little difficulty in attesting SOC 2 compliance and passing an SOC 2 audit." - Steve Alder, Editor-in-Chief, The HIPAA Journal ^[1]

In 2023, nearly 70% of service organizations reported needing to comply with at least six different frameworks related to information security and data privacy ^[32]. This highlights the importance of an integrated approach to compliance. When frameworks are managed independently, gaps and inefficiencies are almost inevitable.

A control mapping strategy can help bridge these gaps. By identifying where SOC 2’s Trust Services Criteria overlap with HIPAA’s safeguards, you can design controls that meet both sets of requirements. For instance, employee access management policies can satisfy SOC 2’s availability criteria while also addressing HIPAA’s workforce security standards. This dual-purpose approach streamlines compliance and reduces redundant work.

The stakes are even higher when you consider that 89% of consumers now see data privacy as a core expectation ^[32]. Mishandling compliance can erode patient trust and harm your organization’s reputation. Managing multiple frameworks in silos increases the risk of overlooking critical requirements, which can lead to compliance failures.

"Managing multiple frameworks can feel daunting, but a unified approach can streamline the process and reduce the redundancy of overlapping controls." - Samantha Boterman, Baker Tilly Cybersecurity Specialist ^[33]

One way to simplify compliance is through centralized policy management. Instead of maintaining separate documentation for each framework, unified policies can address multiple requirements at once. This not only reduces administrative overhead but also ensures consistency across the organization.

Technology can also play a key role. Platforms like Censinet RiskOps™ provide a centralized space for managing risk assessments and compliance documentation across multiple frameworks. This eliminates the need for separate systems and helps break down silos between SOC 2, HIPAA, and other regulatory requirements.

Coordinating compliance efforts also improves resource allocation. Cross-functional teams can address multiple frameworks simultaneously, reducing duplicate work and ensuring that controls meet overlapping requirements. Although achieving SOC 2 compliance doesn’t automatically make you HIPAA compliant (and vice versa), understanding where the frameworks align can strengthen your overall compliance strategy ^[1][2].

Finally, automation can track control effectiveness across frameworks in real time, reducing manual effort and providing visibility into compliance status. By consolidating compliance efforts now, healthcare providers can avoid costly audit issues down the road.

10. Not Using Automated Risk Management Tools

A surprising number of healthcare providers still rely on manual methods - like spreadsheets and paper records - for managing SOC 2 compliance. While these traditional approaches might feel familiar, they come with serious vulnerabilities that can jeopardize audit success and leave organizations exposed to unnecessary risks.

The stakes are especially high in healthcare. To put it in perspective, 62% of healthcare organizations report being "at risk", a figure that’s ten percentage points higher than the global average ^[34]. Even more alarming, 2024 saw 734 breaches that exposed over 276 million records ^[34]. With numbers like these, there’s little room for error.

Manual processes for managing risks are inherently flawed. Spreadsheets require constant manual updates, which increases the likelihood of errors. Compliance teams often face delays, resulting in incomplete or outdated risk assessments when audits roll around. Compare this to the efficiency of automation: a hospital compliance team, for example, could cut its HIPAA documentation time from six weeks to just three days by adopting automated tools ^[34].

But it’s not just about saving time. Spreadsheets lack the advanced capabilities needed for real-time risk management. They can’t automatically identify correlations between risks or provide instant insights into control effectiveness. When auditors request detailed reports, manual systems often fall short, leaving teams scrambling to piece together incomplete or outdated documentation.

Here’s a quick comparison between manual and automated risk management:

Automated tools address these shortcomings head-on. Platforms like Censinet RiskOps™ centralize risk data, provide real-time visibility into controls, and generate audit-ready reports. Unlike manual systems, these tools maintain detailed audit trails, including timestamps and user activity, which are invaluable during SOC 2 audits.

Another major advantage is integration. Automated platforms can connect directly with existing healthcare systems, pulling data automatically. This ensures that risk assessments stay up-to-date with current system configurations and security measures - no manual updates required.

Standardized workflows are another key benefit. Automated systems guide users through compliance processes, flagging potential gaps before they escalate into audit issues. This consistency is especially critical as organizations grow or face increasing regulatory demands. While manual methods might suffice for small teams, they quickly become unmanageable at scale. Automated solutions, on the other hand, can handle growing workloads without requiring additional staff or resources.

Comparison Table

Here’s a breakdown of common SOC 2 audit mistakes in healthcare, their potential impact, and practical ways to address them:

Healthcare organizations often face unique challenges with SOC 2 compliance, managing around 80–100 controls over a six-month to one-year period ^[35]. Tackling these common missteps not only smooths the audit process but also strengthens overall data security.

Conclusion

Achieving SOC 2 compliance in healthcare isn’t just about passing an audit - it’s about maintaining an ongoing commitment to protecting sensitive data. With healthcare data breaches costing an average of $10.93 million per incident ^[17], treating compliance as a one-and-done effort simply isn’t an option.

The most forward-thinking healthcare organizations embed SOC 2 practices into their everyday workflows. This involves scheduling regular internal audits, updating policies as systems evolve, and performing year-round risk assessments. These steps not only keep teams prepared but also drive continuous improvements across systems and processes ^[37].

Employee training plays a pivotal role in maintaining compliance. Since human error is one of the biggest risks, regular staff education is non-negotiable. Keeping employees informed about the latest SOC 2 requirements and their specific responsibilities ensures everyone contributes to safeguarding sensitive information ^[17].

For healthcare providers dealing with outdated systems, compensating controls offer a practical path forward. Instead of overhauling legacy infrastructures overnight, measures like enhanced encryption, stricter access controls, and real-time monitoring can effectively address vulnerabilities while allowing for gradual system upgrades ^[17].

Technology also plays a key role in simplifying compliance. Automated platforms like Censinet RiskOps™ make it easier for healthcare organizations to centralize risk data, monitor control effectiveness in real time, and minimize manual errors that could jeopardize audit results.

FAQs

What’s the difference between SOC 2 and HIPAA compliance, and how can healthcare providers address both effectively?

SOC 2 and HIPAA might have different focuses, but they share a mutual goal: safeguarding sensitive information. SOC 2 is all about ensuring data security and privacy for service organizations across various industries. On the other hand, HIPAA zeroes in on protecting patients' health information (PHI) through its Privacy, Security, and Breach Notification Rules.

Healthcare providers can bring these frameworks together effectively by:

• Aligning SOC 2 controls with HIPAA requirements to cover overlapping areas.
• Consistently updating and testing security measures to meet both sets of standards.
• Using continuous monitoring to spot and address risks before they become issues.

By combining these strategies, healthcare organizations can simplify compliance efforts while keeping patient data well-protected.

What are the best ways for healthcare providers to upgrade legacy systems for SOC 2 compliance while minimizing operational disruptions?

Healthcare providers looking to achieve SOC 2 compliance can improve their legacy systems through incremental modernization strategies. This might involve rehosting, replatforming, or integrating modern interfaces with existing systems. These methods let organizations enhance their infrastructure step by step, avoiding significant disruptions.

Another practical approach is network segmentation, which isolates legacy systems to bolster security and compliance. This method also allows for phased upgrades, ensuring that compliance efforts don’t interfere with daily operations or the quality of patient care. By breaking the process into manageable steps, providers can maintain a smooth transition while meeting SOC 2 standards.

How can healthcare providers ensure continuous staff training to minimize human errors in SOC 2 compliance?

To reduce the chances of human errors in SOC 2 compliance, healthcare providers should emphasize consistent security awareness training. This training should align with both SOC 2 Trust Services Criteria and HIPAA requirements, ensuring staff stays updated on changing risks and compliance expectations.

A blended learning method - combining online courses, in-person workshops, and hands-on scenario exercises - can make training more engaging and effective. It's also important to provide role-specific training, so employees clearly understand how compliance connects to their daily tasks. Regular evaluations and updates to training programs, informed by new threats and audit insights, are essential to fostering a culture that prioritizes compliance.

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