sec_attestation/hipaa.json

{"catalog":{"description":"The Health Insurance Portability and Accountability Act (HIPAA) regulations are divided into several major standards or rules: Privacy Rule, Security Rule, Transactions and Code Sets (TCS) Rule, Unique Identifiers Rule, Breach Notification Rule, Omnibus Final Rule, and the HITECH Act.","uuid":"482aee93-74f8-49df-99a9-b23a175b60f2","datePublished":"1996-08-21T00:00:00","version":"1.0.0","master":false,"url":"https://www.hhs.gov/hipaa/for-professionals/security/guidance/cybersecurity/index.html","abstract":"To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, included Administrative Simplification provisions that required HHS to adopt national standards for electronic health care transactions and code sets, unique health identifiers, and security. At the same time, Congress recognized that advances in electronic technology could erode the privacy of health information. Consequently, Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.","defaultName":"hipaa","title":"HIPAA","lastRevisionDate":"2024-01-29","regulationDatePublished":"1996-08-21","keywords":"HIPAA, Healthcare, Cyber Security, Privacy, Physical Security, HITECH","securityControls":[{"dateLastUpdated":"2022-03-29T00:04:11.8968086","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"","mappings":"","title":"Ensure Confidentiality, Integrity and Availability","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.306(a)","uuid":"5fd1c998-8fc6-4979-a223-6845bdecca8d","dateCreated":"2022-03-29T00:04:11.8967532","id":32716,"family":"GENERAL","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Ensure CIA and protect against threats <br/><br/><h5>Regulation</h5>(a) General requirements. Covered entities must do the following: \r\n(1) Ensure the confidentiality, integrity, and availability of all electronic protected health information the covered entity creates, receives, maintains, or transmits. \r\n(2) Protect against any reasonably anticipated threats or hazards to the security or integrity of such information. \r\n(3) Protect against any reasonably anticipated uses or disclosures of such information that are not permitted or required under subpart E of this part. \r\n(4) Ensure compliance with this subpart by its workforce. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:13.2287772","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"","mappings":"","title":"Flexibility of Approach","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.306(b)","uuid":"5dabd9c5-4629-45a2-b3bd-0237d9cebc6d","dateCreated":"2022-03-29T00:04:13.2287189","id":32717,"family":"GENERAL","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Reasonably consider factors in security compliance <br/><br/><h5>Regulation</h5>(b) Flexibility of approach. \r\n(1) Covered entities may use any security measures that allow the covered entity to reasonably and appropriately implement the standards and implementation specifications as specified in this subpart. \r\n(2) In deciding which security measures to use, a covered entity must take into account the following factors: \r\n(i) The size, complexity, and capabilities of the covered entity. \r\n(ii) The covered entity's technical infrastructure, hardware, and software security capabilities. \r\n(iii) The costs of security measures. \r\n(iv) The probability and criticality of potential risks to electronic protected health information. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:13.9461036","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"","mappings":"","title":"Standards","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.306(c)","uuid":"7a0c765b-1268-4f35-9665-b29971b3e220","dateCreated":"2022-03-29T00:04:13.9461023","id":32718,"family":"GENERAL","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>CEs must comply with standards <br/><br/><h5>Regulation</h5>(c) Standards. A covered entity must comply with the standards as provided in this section and in § 164.308, \r\n§ 164.310, § 164.312, § 164.314, and § 164.316 with respect to all electronic protected health information. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:14.2260879","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"","mappings":"","title":"Implementation Specifications","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.306(d)","uuid":"a05e5049-4a1d-471a-9517-7c7d98113e4a","dateCreated":"2022-03-29T00:04:14.2260869","id":32719,"family":"GENERAL","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Required and Addressable Implementation Specification requirements <br/><br/><h5>Regulation</h5>(d) Implementation specifications. \r\nIn this subpart: \r\n(1) Implementation specifications are required or addressable. If an implementation specification is required, the word \"Required\" appears in parentheses after the title of the implementation specification. If an implementation specification is addressable, the word \"Addressable\" appears in parentheses after the title of the implementation specification. \r\n(2) When a standard adopted in § 164.308, § 164.310, § 164.312, § 164.314, or § 164.316 includes required implementation specifications, a covered entity must implement the implementation specifications. \r\n(3) When a standard adopted in § 164.308, § 164.310, \r\n§ 164.312, § 164.314, or § 164.316 includes addressable implementation specifications, a covered entity must-- \r\n(i) Assess whether each implementation specification is a reasonable and appropriate safeguard in its environment, when analyzed with reference to the likely contribution to protecting the entity's electronic protected health information; and \r\n(ii) As applicable to the entity-- \r\n(A) Implement the implementation specification if reasonable and appropriate; or \r\n(B) If implementing the implementation specification is not reasonable and appropriate-- \r\n(1) Document why it would not be reasonable and appropriate to implement the implementation specification; and \r\n(2) Implement an equivalent alternative measure if reasonable and appropriate. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:14.461832","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"","mappings":"","title":"Maintenance","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.306(e)","uuid":"b6c9192d-b577-4074-aeb9-6c4d2a3f1083","dateCreated":"2022-03-29T00:04:14.4617789","id":32720,"family":"GENERAL","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Ongoing review and modification of security measures <br/><br/><h5>Regulation</h5>(e) Maintenance. Security measures implemented to comply with standards and implementation specifications adopted under § 164.105 and this subpart must be reviewed and modified as needed to continue provision of reasonable and appropriate protection of electronic protected health information as described at § 164.316. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:14.8919289","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Privacy Officer - Awareness</li><li>Compliance Office - Notification</li><li>Security Officer - Policy</li><li>IT Managers - Procedures</li><li>Network or System Administrator - Procedures</li><li>DB Administrator - Procedures</li><li>Help Desk or Tech Support - Procedures</li></ul>","enhancements":"","mappings":"","title":"Security Management Process","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(1)(i)","uuid":"70662b5d-25e4-4432-9a98-0e5836eb29ae","dateCreated":"2022-03-29T00:04:14.8919278","id":32721,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to manage security violations <br/><br/><h5>Regulation</h5>Implement policies and procedures to prevent, detect, contain and correct security violations <br/>"},{"dateLastUpdated":"2022-03-29T00:04:15.1557387","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Privacy Officer - Awareness</li><li>Compliance Office - Notification</li><li>Security Officer - Oversee</li><li>IT Managers - Assessment</li><li>Network or System Administrator - Assessment</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Risk Analysis","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(1)(ii)(A)","uuid":"b97e9bdd-e5cf-45ed-8fe1-cc0efeb5add8","dateCreated":"2022-03-29T00:04:15.1557378","id":32722,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Conduct vulnerability assessment <br/><br/><h5>Regulation</h5>Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:15.3442331","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Privacy Officer - Awareness</li><li>Compliance Office - Notification</li><li>Security Officer - Policy</li><li>IT Managers - Procedures</li><li>Network or System Administrator - Measures</li><li>Facilities Managers - Measures</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Risk Management","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(1)(ii)(B)","uuid":"43d3d4a4-6bc9-4be3-bfb4-ed034123db2a","dateCreated":"2022-03-29T00:04:15.3442322","id":32723,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Implement security measures to reduce risk of security breaches <br/><br/><h5>Regulation</h5>Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with Sec 164.206(a). <br/>"},{"dateLastUpdated":"2022-03-29T00:04:15.548415","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Records</li><li>Security Officer - Policy</li><li>IT Managers - Management</li><li>Human Resources - Records</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Sanction Policy","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(1)(ii)(C)","uuid":"24f1b9f8-29a3-4c84-b4a9-f187412d7aa4","dateCreated":"2022-03-29T00:04:15.5484116","id":32724,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Worker sanction for P&P violations <br/><br/><h5>Regulation</h5>Apply appropriate sanctions against workforce members who fail to comply with the security policies and procedures of the covered entity. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:15.9388982","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Event Rept.</li><li>IT Managers - Event Rept.</li><li>Network or System Administrator - Sys Auditing</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Information System Activity Review","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(1)(ii)(D)","uuid":"54c04c70-9df7-417d-92a9-f45c36336869","dateCreated":"2022-03-29T00:04:15.9388971","id":32725,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures to review system activity <br/><br/><h5>Regulation</h5>Implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:16.2073609","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Authority</li></ul>","enhancements":"","mappings":"","title":"Assigned Security Responsibility","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(2)","uuid":"722bd5c3-c6ee-47fe-a387-e4856e1634ff","dateCreated":"2022-03-29T00:04:16.2073598","id":32726,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Identify security official responsible for P&P <br/><br/><h5>Regulation</h5>Identify the security official who is responsible for the development and implementation of the policies and procedures required by this subpart for the entity. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:16.396014","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Policy</li><li>IT Managers - Manage</li><li>Facilities Managers - Manage</li></ul>","enhancements":"","mappings":"","title":"Workforce Security","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(3)(i)","uuid":"655e58ec-e96e-4fa7-ad8d-e19b1a421051","dateCreated":"2022-03-29T00:04:16.396013","id":32727,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Implement P&P to ensure appropriate PHI access <br/><br/><h5>Regulation</h5>Implement policies and procedures to ensure that all members of its workforce have appropriate access to electronic protected health information, as provided under paragraph (a)(4) of this section, and to prevent those workforce members who do not have access under paragraph (a))(4) of this section from obtaining access to electronic protected health information. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:16.5738338","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Policy</li><li>IT Managers - Authorize</li><li>Network or System Administrator - Supervise</li><li>Facilities Managers - Supervise</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Authorization and/or Supervision","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(3)(ii)(A)","uuid":"ebfb427a-420d-4074-b4c3-9ac2fb88437c","dateCreated":"2022-03-29T00:04:16.5738328","id":32728,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Authorization/supervision for PHI access <br/><br/><h5>Regulation</h5>Implement procedures for authorization and/or supervision of workforce members who work with electronic protected health information or in locations where it might be accessed. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:16.9985164","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Policy</li><li>IT Managers - Clearance</li><li>Facilities Managers - Clearance</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Workforce Clearance Procedure","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(3)(ii)(B)","uuid":"8772e057-b8b9-4b57-96bb-a123c931e745","dateCreated":"2022-03-29T00:04:16.9985155","id":32729,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures to ensure appropriate PHI access <br/><br/><h5>Regulation</h5>Implement procedures to determine that the access of a workforce member to electronic protected health information is appropriate. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:17.279828","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Policy</li><li>IT Managers - Manage</li><li>Facilities Managers - Manage</li><li>Human Resources - Procedures</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Termination Procedures","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(3)(ii)(C)","uuid":"41e074ce-9113-40eb-8600-8afb99900115","dateCreated":"2022-03-29T00:04:17.2798267","id":32730,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures to terminate PHI access <br/><br/><h5>Regulation</h5>Implement procedures for termination access to electronic protected health information when the employment of a workforce member ends or as required by determination made as specified in paragraph (a)(3)(ii)(B) of this section. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:17.4830863","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Privacy Officer - Awareness</li><li>Compliance Office - Job Desp</li><li>Security Officer - Awareness</li><li>IT Managers - Awareness</li><li>Facilities Managers - Awareness</li><li>Human Resources - Awareness</li></ul>","enhancements":"","mappings":"","title":"Information Access Management","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(4)(i)","uuid":"302e3037-54c4-4d67-8f9b-b586c2f99c0d","dateCreated":"2022-03-29T00:04:17.483085","id":32731,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to authorize access to PHI <br/><br/><h5>Regulation</h5>Implement policies and procedures for authorizing access to electronic protected health information that are consistent with the applicable requirements of subpart E of this part. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:17.678152","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Isolation Health Clearinghouse Functions","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(4)(ii)(A)","uuid":"c3342875-35c7-46a7-8cae-474f153b360e","dateCreated":"2022-03-29T00:04:17.6781514","id":32732,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to separate PHI from other operations <br/><br/><h5>Regulation</h5>If a health care clearinghouse is part of a larger organization, the clearinghouse must implement polices and procedures that protect the electronic protected health information of the clearinghouse from unauthorized access by the larger organization. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:18.0651641","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Addressable","mappings":"","title":"Access Authorization","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(4)(ii)(B)","uuid":"7888dbe8-8440-4dcc-b47f-4321dbf03958","dateCreated":"2022-03-29T00:04:18.065163","id":32733,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to authorize access to PHI <br/><br/><h5>Regulation</h5>Implement policies and procedures for granting access to electronic protected health information, for example, through access to a workstation, transaction, program, process or other mechanism. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:18.335645","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>IT Managers - Change Form</li><li>Help Desk or Tech Support - Change Form</li><li>Facilities Managers - Change Form</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Access Establishment and Modification","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(4)(ii)(C)","uuid":"b293e82e-dbdf-4b39-b0ea-3bfac629a87b","dateCreated":"2022-03-29T00:04:18.3356439","id":32734,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to grant access to PHI <br/><br/><h5>Regulation</h5>Implement policies and procedures that, based upon the entity's access authorization policies, establish, document, review, and modify a user's right of access to a workstation, transaction, program, or process. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:18.5538862","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"","mappings":"","title":"Security Awareness Training","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(5)(i)","uuid":"66a8810d-a984-4ebc-bab3-1ed4ece6765f","dateCreated":"2022-03-29T00:04:18.5538852","id":32735,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Training program for workers and managers <br/><br/><h5>Regulation</h5>Implement a security awareness and training program for all members of its workforce (including management). <br/>"},{"dateLastUpdated":"2022-03-29T00:04:19.0236913","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Security Reminders","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(5)(ii)(A)","uuid":"119e58f0-8524-43c4-a1d6-bb8da3907197","dateCreated":"2022-03-29T00:04:19.0236896","id":32736,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Distribute periodic security updates <br/><br/><h5>Regulation</h5>Periodic security updates. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:19.2203249","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Protection from Malicious Software","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(5)(ii)(B)","uuid":"045c8ca1-3c6c-4b5b-bd38-27308d9b8782","dateCreated":"2022-03-29T00:04:19.2203241","id":32737,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures to guard against malicious software <br/><br/><h5>Regulation</h5>Procedures for guarding against, detecting, and reporting malicious software. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:19.6973327","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Log-in Monitoring","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(5)(ii)(C)","uuid":"f76ee50c-f5b1-4be1-bbbe-918e77aaf547","dateCreated":"2022-03-29T00:04:19.697332","id":32738,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures and monitoring of log-in attempts <br/><br/><h5>Regulation</h5>Procedures for monitoring log-in attempts and reporting discrepancies. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:20.1563448","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Password Management","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(5)(ii)(D)","uuid":"2b2e9c33-d9ce-4b61-aadd-84f2c13cc665","dateCreated":"2022-03-29T00:04:20.1563437","id":32739,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures for password management <br/><br/><h5>Regulation</h5>Procedures for creating, changing, and safeguarding passwords. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:20.619754","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"","mappings":"","title":"Security Incident Procedures","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(6)(i)","uuid":"4107c387-3aa8-4211-bf26-c6b2fc95cf36","dateCreated":"2022-03-29T00:04:20.6197532","id":32740,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to manage security incidents <br/><br/><h5>Regulation</h5>Implement policies and procedures to address security incidents. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:20.8182988","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Incident Rep.</li><li>IT Managers - Incident Rep.</li><li>Network or System Administrator - Monitor</li><li>Help Desk or Tech Support - Incident Rep.</li><li>Facilities Managers - Monitor</li><li>End Users with PHI Access - Incident Rep.</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Response and Reporting","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(6)(ii)","uuid":"9dbc60f5-a05c-4786-954d-f5c5a2804b31","dateCreated":"2022-03-29T00:04:20.8182978","id":32741,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Mitigate and document security incidents <br/><br/><h5>Regulation</h5>Identify and respond to suspected or known security incidents; mitigate, to the extent practicable, harmful effects of security incidents that are known to the covered entity; and document security incidents and their outcomes. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:21.2334749","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>IT Managers - BCP</li><li>Network or System Administrator - Recovery</li><li>DB Administrator - Recovery</li></ul>","enhancements":"","mappings":"","title":"Contingency Plan","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(7)(i)","uuid":"a6b1be5e-097c-4e86-a5b0-9ad49b07bdd4","dateCreated":"2022-03-29T00:04:21.2334742","id":32742,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Emergency response P&P <br/><br/><h5>Regulation</h5>Establish (and implement as needed) policies and procedures for responding to an emergency or other occurrence (for example, fire, vandalism, system failure, and natural disaster) that damages systems that contain electronic protected health information. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:21.6099216","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Planning</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Data Backup Plan","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(7)(ii)(A)","uuid":"25f54b75-4093-4b97-96e7-7cda17936f99","dateCreated":"2022-03-29T00:04:21.609921","id":32743,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Data backup planning & procedures <br/><br/><h5>Regulation</h5>Establish and implement procedures to create and maintain retrievable exact copies of electronic protected health information. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:21.7994662","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Planning</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Disaster Recovery Plan","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(7)(ii)(B)","uuid":"f233480b-e308-4821-89a4-f7c0edbaa30f","dateCreated":"2022-03-29T00:04:21.7994656","id":32744,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Data recovery planning & procedures <br/><br/><h5>Regulation</h5>Establish (and implement as needed) procedures to restore loss of data. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:22.1864842","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Plan</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Emergency Mode Operation Plan","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(7)(ii)(C)","uuid":"203ee67d-98c6-4744-b348-0bbbaa37fb84","dateCreated":"2022-03-29T00:04:22.1864833","id":32745,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Business continuity procedures <br/><br/><h5>Regulation</h5>Establish (and implement as needed) procedures to enable continuation of critical business processes for protection of the security of electronic protected health information while operation in emergency mode. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:22.3746427","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Policy</li><li>IT Managers - Oversight</li><li>Network or System Administrator - Test. Proc.</li><li>DB Administrator - Test. Proc.</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Testing and Revision Procedures","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(7)(ii)(D)","uuid":"2fedb2ee-9b42-42c7-8119-20d69ea37676","dateCreated":"2022-03-29T00:04:22.3746422","id":32746,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Contingency planning periodic testing procedures <br/><br/><h5>Regulation</h5>Implement procedures for periodic testing and revision of contingency plans. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:22.748355","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Privacy Officer - Awareness</li><li>Compliance Office - Notification</li><li>Security Officer - Oversee</li><li>IT Managers - Assessment</li><li>Network or System Administrator - Assessment</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Applications and Data Criticality Analysis","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(7)(ii)(E)","uuid":"235be081-e2da-43e0-9af7-0011440a2ec5","dateCreated":"2022-03-29T00:04:22.7483544","id":32747,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Prioritize data and system criticality for contingency planning <br/><br/><h5>Regulation</h5>Assess the relative criticality of specific applications and data in support of other contingency plan components. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:23.1504623","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Privacy Officer - Awareness</li><li>Compliance Office - Notification</li><li>Security Officer - Oversee</li><li>IT Managers - Assessment</li><li>Network or System Administrator - Assessment</li></ul>","enhancements":"","mappings":"","title":"Evaluation","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(a)(8)","uuid":"6c66547a-aa93-4a3e-ad52-d2b9e7450701","dateCreated":"2022-03-29T00:04:23.1504615","id":32748,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Periodic security evaluation <br/><br/><h5>Regulation</h5>Perform a periodic technical and nontechnical evaluation, based initially upon the standards implemented under this rule and subsequently, in response to environmental or operational changes affecting the security of electronic protected health information, that established the extent to which an entity's security policies and procedures meet the requirements of this subpart. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:23.354398","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>IT Managers - BAC Mgmt.</li></ul>","enhancements":"","mappings":"","title":"Business Associate Contracts and Other Arrangements","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(b)(1)","uuid":"e75c13d0-b5f5-4620-b6d4-bc5b1ce61344","dateCreated":"2022-03-29T00:04:23.3543968","id":32749,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>CE implement BACs to ensure safeguards <br/><br/><h5>Regulation</h5>A covered entity, in accordance with § 164.306, may permit a business associate to create, receive, maintain, or transmit electronic protected health information on the covered entity's behalf only if the covered entity obtains satisfactory assurances, in accordance with § 164.314(a) that the business associate will appropriately safeguard the information. \r\n(2) This standard does not apply with respect to - \r\n(i) The transmission by a covered entity of electronic protected health information to a health care provider concerning the treatment of an individual. \r\n(ii) The transmission of electronic protected health information by a group health plan or an HMO or health insurance issuer on behalf of a group health plan to a plan sponsor, to the extent that the requirements of § 164.314(b) and § 164.504(f) apply and are met; or \r\n(iii) The transmission of electronic protected health information from or to other agencies providing the services at § 164.502(e)(1)(ii)(C), when the covered entity is a health plan that is a government program providing public benefits, if the requirements of § 164.502(e)(1)(ii)(C) are met. \r\n(3) A covered entity that violates the satisfactory assurances it provided as a business associate of another covered entity will be in noncompliance with the standards, implementation specifications, and requirements of this paragraph and § 164.314(a). <br/>"},{"dateLastUpdated":"2022-03-29T00:04:23.7579246","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Written Contract","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.308(b)(4)","uuid":"6bfe7b0e-1fb7-49e0-a316-0757f0898e49","dateCreated":"2022-03-29T00:04:23.757924","id":32750,"family":"ADMINISTRATIVE SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Implement compliant BACs <br/><br/><h5>Regulation</h5>Document the satisfactory assurances required by paragraph (b)(1) of this section through a written contract or other arrangement with the business associate that meets the applicable requirements of § 164.314(a). <br/>"},{"dateLastUpdated":"2022-03-29T00:04:23.9467458","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Policy</li><li>Security Officer - Policy</li><li>Facilities Managers - Oversight</li></ul>","enhancements":"","mappings":"","title":"Facility Access Controls","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310 (a)(1)","uuid":"52419ea3-2ac5-4db7-8e81-9b2872c7ae7e","dateCreated":"2022-03-29T00:04:23.946745","id":32751,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to limit access to systems and facilities <br/><br/><h5>Regulation</h5>Implement policies and procedures to limit physical access to its electronic information systems and the facility or facilities in which they are housed, while ensuring that properly authorized access is allowed. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:24.3203738","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Notification</li><li>Security Officer - Notification</li><li>Facilities Managers - Planning</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Contingency Operations","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(a)(2)(i)","uuid":"7b0ebd0f-3a02-45cf-acb6-9412711a9441","dateCreated":"2022-03-29T00:04:24.3203725","id":32752,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures to support emergency operations and recovery <br/><br/><h5>Regulation</h5>Establish (and implement as needed) procedures that allow facility access in support of restoration of lost data under the disaster recovery plan and emergency mode operations plan in the event of an emergency. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:24.4932214","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Notification</li><li>Security Officer - Notification</li><li>Facilities Managers - Mgmt.</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Facility Security Plan","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(a)(2)(ii)","uuid":"d1365e1d-9986-4d37-af0e-e1a8ab136b38","dateCreated":"2022-03-29T00:04:24.4932207","id":32753,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to safeguard equipment and facilities <br/><br/><h5>Regulation</h5>Implement policies and procedures to safeguard the facility and the equipment there in from unauthorized physical access, tampering, and theft. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:24.850096","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Notification</li><li>Security Officer - Notification</li><li>Facilities Managers - Oversight</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Access Control Validation Procedures","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(a)(2)(iii)","uuid":"99331122-f72f-400a-802f-f7d59f02d1dd","dateCreated":"2022-03-29T00:04:24.8500952","id":32754,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Facility access procedures for personnel <br/><br/><h5>Regulation</h5>Implement procedures to control and validate a person's access to facilities based on their role or function, including visitor control, and control of access to software programs for testing and revision. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:25.2426604","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Addressable","mappings":"","title":"Maintenance Records","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(a)(2)(iv)","uuid":"4052867e-1894-4325-a2a8-68a74eb049bf","dateCreated":"2022-03-29T00:04:25.2426596","id":32755,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to document security-related repairs and modifications <br/><br/><h5>Regulation</h5>Implement policies and procedures to document repairs and modifications to the physical components of a facility that are related to security (for example, hardware, walls, doors, and locks). <br/>"},{"dateLastUpdated":"2022-03-29T00:04:25.4327135","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>Facilities Managers - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"","mappings":"","title":"Workstation Use","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(b)","uuid":"9ee5b39b-86c8-4f74-86ef-1c9bcef62e76","dateCreated":"2022-03-29T00:04:25.4327128","id":32756,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to specify workstation environment & use <br/><br/><h5>Regulation</h5>Implement policies and procedures that specify the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific workstation or class of workstation that can access electronic protected health information. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:25.8473402","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>Facilities Managers - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"","mappings":"","title":"Workstation Security","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(c)","uuid":"58dba6df-2a6e-4f34-aee9-a5c94570d339","dateCreated":"2022-03-29T00:04:25.8473393","id":32757,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Physical safeguards for workstation access <br/><br/><h5>Regulation</h5>Implement physical safeguards for all workstations that access electronic protected health information, to restrict access to authorized users. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:26.0641094","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>Facilities Managers - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"","mappings":"","title":"Device and Media Controls","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(d)(1)","uuid":"fbe6a7f6-d706-4352-84e7-e135ceda12e3","dateCreated":"2022-03-29T00:04:26.0641087","id":32758,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to govern receipt and removal of hardware and media <br/><br/><h5>Regulation</h5>Implement policies and procedures that govern the receipt and removal of hardware and electronic media that contain electronic protected health information into and out of a facility, and the movement of these items within the facility. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:26.425057","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>Facilities Managers - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Disposal","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(d)(2)(i)","uuid":"2e917f67-d2d8-4683-9062-797455313268","dateCreated":"2022-03-29T00:04:26.425056","id":32759,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to manage media and equipment disposal <br/><br/><h5>Regulation</h5>Implement policies and procedures to address the final disposition of electronic protected health information, and/or the hardware or electronic media on which it is stored. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:26.8240599","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>Facilities Managers - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Media Re-use","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(d)(2)(ii)","uuid":"7e72070f-0a68-4d5d-aee7-830cf781587a","dateCreated":"2022-03-29T00:04:26.8240593","id":32760,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to remove PHI from media and equipment <br/><br/><h5>Regulation</h5>Implement procedures for removal of electronic protected health information from electronic media before the media are made available for re-use. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:27.0187976","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Help Desk or Tech Support - Sec. Training</li><li>Facilities Managers - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Accountability","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(d)(2)(iii)","uuid":"0a3b85cb-eddb-492d-b03b-1639b6c84ace","dateCreated":"2022-03-29T00:04:27.0187968","id":32761,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Document hardware and media movement <br/><br/><h5>Regulation</h5>Maintain a record of the movements of hardware and electronic media and any person responsible therefore. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:27.4259056","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Notification</li><li>Security Officer - Oversight</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li><li>DB Administrator - Administration</li><li>Facilities Managers - Mgmt.</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Data Backup and Storage","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.310(d)(2)(iv)","uuid":"437c5eca-f382-4a06-be18-7a5a3053ba67","dateCreated":"2022-03-29T00:04:27.4259047","id":32762,"family":"PHYSICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Backup PHI before moving equipment <br/><br/><h5>Regulation</h5>Create a retrievable, exact copy of electronic protected health information, when needed, before movement of equipment.  <br/>"},{"dateLastUpdated":"2022-03-29T00:04:27.627139","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"","mappings":"","title":"Access Control ","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(a)(1)","uuid":"d621feea-05c0-4214-b4a4-7fcee3d90fd5","dateCreated":"2022-03-29T00:04:27.6271383","id":32763,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Technical (administrative) P&P to manage PHI access <br/><br/><h5>Regulation</h5>Implement technical policies and procedures for electronic information systems that maintain electronic protected health information to allow access only to those persons or software programs that have been granted access rights as specified in § 164.308(a)(4). <br/>"},{"dateLastUpdated":"2022-03-29T00:04:27.9932638","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Network or System Administrator - Administration</li><li>Help Desk or Tech Support - Sec. Training</li><li>Facilities Managers - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Unique User Identification","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(a)(2)(i)","uuid":"98b0054b-0adc-47c5-968a-37c1682d2d52","dateCreated":"2022-03-29T00:04:27.9932632","id":32764,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Assign unique IDs to support tracking <br/><br/><h5>Regulation</h5>Assign a unique name and/or number for identifying and tracking user identity. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:28.4022715","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Policy</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li><li>Help Desk or Tech Support - Administration</li><li>Facilities Managers - Mgmt.</li><li>End Users with PHI Access - Awareness</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Emergency Access Procedure","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(a)(2)(ii)","uuid":"f14b080d-3f4d-4f5d-a5d4-7196e3c3e023","dateCreated":"2022-03-29T00:04:28.4022707","id":32765,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures to support emergency access <br/><br/><h5>Regulation</h5>Establish (and implement as needed) procedures for obtaining necessary electronic protected health information during an emergency.  <br/>"},{"dateLastUpdated":"2022-03-29T00:04:28.5909471","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Policy</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li><li>Help Desk or Tech Support - Sec. Training</li><li>Facilities Managers - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Automatic Logoff","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(a)(2)(iii)","uuid":"a6100ed5-6f3b-40b7-89ef-2dd5b76e99bc","dateCreated":"2022-03-29T00:04:28.5909464","id":32766,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Session termination mechanisms <br/><br/><h5>Regulation</h5>Implement electronic procedures that terminate an electronic session after a predetermined time of inactivity. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:28.9958714","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Notification</li><li>Security Officer - Policy</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Encryption and Decryption","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(a)(2)(iv)","uuid":"22c62da6-9960-4175-a3ef-b887d7b0d31c","dateCreated":"2022-03-29T00:04:28.9958708","id":32767,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Mechanism for encryption of stored PHI <br/><br/><h5>Regulation</h5>Implement a mechanism to encrypt and decrypt electronic protected health information. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:29.1995612","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Notification</li><li>Security Officer - Policy</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li></ul>","enhancements":"","mappings":"","title":"Audit Controls","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(b)","uuid":"79b5a4c0-879d-4e72-a3d3-4f3470277d86","dateCreated":"2022-03-29T00:04:29.1995603","id":32768,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures and mechanisms for monitoring system activity <br/><br/><h5>Regulation</h5>Implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:29.5931824","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Notification</li><li>Security Officer - Policy</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li></ul>","enhancements":"","mappings":"","title":"Integrity","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(c)(1)","uuid":"4e9100bf-5437-4b61-9324-59793a4e945e","dateCreated":"2022-03-29T00:04:29.5931818","id":32769,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to safeguard PHI unauthorized alteration <br/><br/><h5>Regulation</h5>Implement policies and procedures to protect electronic protected health information from improper alteration or destruction. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:29.9980521","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Plan</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Mechanism to Authenticate Electronic Protected Health Information","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(c)(2)","uuid":"eac1344d-a0da-499c-b883-fcd69673ed7f","dateCreated":"2022-03-29T00:04:29.9980511","id":32770,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Mechanisms to corroborate PHI not altered <br/><br/><h5>Regulation</h5>Implement electronic mechanisms to corroborate that electronic protected health information has not been altered or destroyed in an unauthorized manner. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:30.1995416","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Policy</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li><li>Help Desk or Tech Support - Administration</li></ul>","enhancements":"","mappings":"","title":"Person or Entity Authentication","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(d)","uuid":"6d2cc80d-9108-4dc3-857d-cce746c20208","dateCreated":"2022-03-29T00:04:30.1995408","id":32771,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Procedures to verify identities <br/><br/><h5>Regulation</h5>Implement procedures to verify that a person or entity seeking access to electronic protected health information is the one claimed. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:30.604133","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Policy</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li></ul>","enhancements":"","mappings":"","title":"Transmission Security","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(e)(1)","uuid":"667635e1-72d0-40be-82e1-dac628c13e2a","dateCreated":"2022-03-29T00:04:30.6041323","id":32772,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Measures to guard against unauthorized access to transmitted PHI <br/><br/><h5>Regulation</h5>Implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:31.0127251","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Security Officer - Policy</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Integrity Controls","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(e)(2)(i)","uuid":"5bf0a886-02e0-437c-989e-66621e4c3f07","dateCreated":"2022-03-29T00:04:31.0127241","id":32773,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Measures to ensure integrity of PHI on transmission <br/><br/><h5>Regulation</h5>Implement security measures to ensure that electronically transmitted electronic protected health information is not improperly modified without detection until disposed of. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:31.2181535","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Privacy Officer - Awareness</li><li>Compliance Office - Policy</li><li>Security Officer - Policy</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li><li>Help Desk or Tech Support - Sec. Training</li><li>Facilities Managers - Sec. Training</li><li>End Users with PHI Access - Sec. Training</li></ul>","enhancements":"Implementation: Addressable","mappings":"","title":"Encryption","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.312(e)(2)(ii)","uuid":"8c6f00eb-cbb6-4bfa-b262-779fa7c6d910","dateCreated":"2022-03-29T00:04:31.2181529","id":32774,"family":"TECHNICAL SAFEGUARDS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Mechanism for encryption of transmitted PHI <br/><br/><h5>Regulation</h5>Implement a mechanism to encrypt electronic protected health information whenever deemed appropriate. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:31.6263971","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Privacy Officer - Awareness</li><li>Compliance Office - Oversight</li><li>Security Officer - Oversight</li><li>IT Managers - Mgmt.</li></ul>","enhancements":"","mappings":"","title":"Business Associate Contracts or Other Arrangements","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.314(a)(1)","uuid":"a7577095-6dfb-49ac-9913-387268e5a014","dateCreated":"2022-03-29T00:04:31.6263964","id":32775,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>CE must ensure BA safeguards PHI <br/><br/><h5>Regulation</h5>(i) The contract or other arrangement between the covered entity and its business associate required by \r\n§ 164.308(b) must meet the requirements of paragraph (a)(2)(i) or (a)(2)(ii) of this section, as applicable. \r\n(ii) A covered entity is not in compliance with the standards in § 164.502(e) and paragraph (a) of this section if the covered entity knew of a pattern of an activity or practice of the business associate that constituted a material breach or violation of the business associate's obligation under the contract or other arrangement, unless the covered entity took reasonable steps to cure the breach or end the violation, as applicable, and, if such steps were unsuccessful. \r\n(A) Terminated the contract or arrangement, if feasible; or \r\n(B) If termination is not feasible, reported the problem to the Secretary. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:31.8063651","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Business Associate Contracts","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.314(a)(2)","uuid":"47b05a45-e155-4720-a57d-b2b530d44e1e","dateCreated":"2022-03-29T00:04:31.8063644","id":32776,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>BACs must contain security language <br/><br/><h5>Regulation</h5>(i) Business associate contracts. The contract between a covered entity and a business associate must provide that the business associate will-- \r\n(A) Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits on behalf of the covered entity as required by this subpart; \r\n(B) Ensure that any agent, including a subcontractor, to whom it provides such information agrees to implement reasonable and appropriate safeguards to protect it; \r\n(C) Report to the covered entity any security incident of which it becomes aware; \r\n(D) Authorize termination of the contract by the covered entity, if the covered entity determines that the business associate has violated a material term of the contract. \r\n(ii) Other arrangements. \r\n(A) When a covered entity and its business associate are both governmental entities, the covered entity is in compliance with paragraph (a)(1) of this section, if - \r\n(1) It enters into a memorandum of understanding with the business associate that contains terms that accomplish the objectives of paragraph (a)(2)(i) of this section; or \r\n(2) Other law (including regulations adopted by the covered entity or its business associate) contains requirements applicable to the business associate that accomplish the objectives of paragraph (a)(2)(i) of this section. \r\n(B) If a business associate is required by law to perform a function or activity on behalf of a covered entity or to provide a service described in the definition of business associate as specified in § 160.103 of this subchapter to a covered entity, the covered entity may permit the business associate to create, receive, maintain, or transmit electronic protected health information on its behalf to the extent necessary to comply with the legal mandate without meeting the requirements of paragraph (a)(2)(i) of this section, provided that the covered entity attempts in good faith to obtain satisfactory assurances as required by paragraph (a)(2)(ii)(A) of this section, and documents the attempt and the reasons that these assurances cannot be obtained. \r\n(C) The covered entity may omit from its other arrangements authorization of the termination of the contract by the covered entity, as required by paragraph (a)(2)(i)(D) of this section if such authorization is inconsistent with the statutory obligations of the covered entity or its business associate. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:32.1869127","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"","mappings":"","title":"Requirements for Group Health Plans","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.314(b)(1)","uuid":"2c46c98d-4a3f-4d18-b808-9bee796a536f","dateCreated":"2022-03-29T00:04:32.186912","id":32777,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Plan documents must reflect security safeguards <br/><br/><h5>Regulation</h5>Except when the only electronic protected health information disclosed to a plan sponsor is disclosed pursuant to § 164.504(f)(1)(ii) or (iii), or as authorized under § 164.508, a group health plan must ensure that its plan documents provide that the plan sponsor will reasonably and appropriately safeguard electronic protected health information created, received, maintained, or transmitted to or by the plan sponsor on behalf of the group health plan. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:32.5856426","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Implement Safeguards","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.314(b)(2)(i)","uuid":"3125c72f-04cb-4295-85a1-1068ab477c39","dateCreated":"2022-03-29T00:04:32.5856418","id":32778,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Plan sponsor to implement safeguards as appropriate <br/><br/><h5>Regulation</h5>The plan documents of the group health plan must be amended to incorporate provisions to require the plan sponsor to-- \r\n(i) Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits on behalf of the group health plan; <br/>"},{"dateLastUpdated":"2022-03-29T00:04:32.7896006","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Ensure Adequate Separation","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.314(b)(2)(ii)","uuid":"c9fb2a3a-0249-4562-a46a-3b2d4ea858de","dateCreated":"2022-03-29T00:04:32.7895998","id":32779,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Security measures to separate PHI from plan sponsor and plan <br/><br/><h5>Regulation</h5>Ensure that the adequate separation required by \r\n§ 164.504(f)(2)(iii) is supported by reasonable and appropriate security measures; <br/>"},{"dateLastUpdated":"2022-03-29T00:04:33.0825522","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Ensure Agents Safeguard","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.314(b)(2)(iii)","uuid":"315b8b89-d55a-4b37-bdf7-daaad42f89de","dateCreated":"2022-03-29T00:04:33.0825512","id":32780,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Ensure subcontractors safeguard PHI <br/><br/><h5>Regulation</h5>Ensure that any agent, including a subcontractor, to whom it provides this information agrees to implement reasonable and appropriate security measures to protect the information; and <br/>"},{"dateLastUpdated":"2022-03-29T00:04:33.2643493","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Privacy Officer - Awareness</li><li>Compliance Office - Notification</li><li>Security Officer - Oversight</li><li>IT Managers - Mgmt.</li></ul>","enhancements":"Implementation: Required","mappings":"","title":"Report Security Incidents","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.314(b)(2)(iv)","uuid":"dc2ce6e3-7a70-4d06-b7f6-3db54464bfae","dateCreated":"2022-03-29T00:04:33.2643486","id":32781,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Plan sponsors report breaches to health plan <br/><br/><h5>Regulation</h5>Report to the group health plan any security incident of which it becomes aware.  <br/>"},{"dateLastUpdated":"2022-03-29T00:04:33.7324914","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"<h5>Roles and Responsibilities</h5><br/><ul><li>Compliance Office - Policy</li><li>Security Officer - Procedures</li><li>IT Managers - Mgmt.</li><li>Network or System Administrator - Administration</li></ul>","enhancements":"","mappings":"","title":"Policies and Procedures","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.316(a)","uuid":"9ff9e25d-633c-4c67-a5b3-d2d0a5e6a751","dateCreated":"2022-03-29T00:04:33.7324906","id":32782,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>P&P to ensure safeguards to PHI <br/><br/><h5>Regulation</h5>A covered entity must, in accordance with § 164.306: Implement reasonable and appropriate policies and procedures to comply with the standards, implementation specifications, or other requirements of this subpart, taking into account those factors specified in § 164.306(b)(2)(i), (ii), (iii), and (iv). This standard is not to be construed to permit or excuse an action that violates any other standard, implementation specification, or other requirements of this subpart. A covered entity may change its policies and procedures at any time, provided that the changes are documented and are implemented in accordance with this subpart. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:33.918094","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Documentation","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.316(b)(1)","uuid":"8f73d8f9-3c8c-4491-8e5a-19036fe19cec","dateCreated":"2022-03-29T00:04:33.918093","id":32783,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Document P&P and actions & activities <br/><br/><h5>Regulation</h5>Documentation.\r\n(i) Maintain the policies and procedures implemented to comply with this subpart in written (which may be electronic) form; and\r\n(ii) If an action, activity or assessment is required by this subpart to be documented, maintain a written (which may be electronic) record of the action, activity, or assessment. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:34.338235","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Time Limit","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.316(b)(2)(i)","uuid":"4808746a-4616-4cc4-8032-297effaa3ccf","dateCreated":"2022-03-29T00:04:34.3382344","id":32784,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Retain documentation for 6 years <br/><br/><h5>Regulation</h5>Retain the documentation required by paragraph (b)(1) of this section for 6 years from the date of its creation or the date when it last was in effect, whichever is later. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:34.7798363","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Availability","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.316(b)(2)(ii)","uuid":"d39e13c4-a54a-4ef7-9d28-d3232e359d46","dateCreated":"2022-03-29T00:04:34.7798357","id":32785,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Documentation available to system administrators <br/><br/><h5>Regulation</h5>Make documentation available to those persons responsible for implementing the procedures to which the documentation pertains. <br/>"},{"dateLastUpdated":"2022-03-29T00:04:35.2054447","subControls":"","lastUpdatedById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","practiceLevel":"","tenantsId":1,"relatedControls":"","enhancements":"Implementation: Required","mappings":"","title":"Updates","weight":0,"catalogueID":205,"createdById":"52f86957-eb18-4ec5-bddd-ae54d93bfcce","archived":false,"assessmentPlan":"","controlId":"164.316(b)(2)(iii)","uuid":"cad0a88e-60f9-4545-8d82-7be3a74a465d","dateCreated":"2022-03-29T00:04:35.2054438","id":32786,"family":"ORGANIZATIONAL REQUIREMENTS","references":"","isPublic":true,"controlType":"Stand-Alone","description":"<h5>Description</h5>Periodic review and updates to changing needs <br/><br/><h5>Regulation</h5>Review documentation periodically, and update as needed, in response to environmental or operational changes affecting the security of the electronic protected health information. <br/>"}]}}