hipaa-as-6 Critical priority Administrative Safeguards / Security Incident Procedures

Implement policies and procedures to address security incidents involving ePHI

Security incidents involving ePHI are not a matter of if but when. HIPAA requires organizations to identify and respond to security incidents, mitigate harmful effects to the extent practicable, and document incidents and their outcomes. A security incident is any attempted or successful unauthorized access, use, disclosure, modification, or destruction of ePHI or systems containing ePHI. A well-defined incident response process limits damage, supports breach notification determinations, and demonstrates due diligence to regulators.

8h estimated effort

hipaa incident-response breach-notification security-operations

Implementation steps

1

Define a security incident response policy and procedure

Write a documented incident response policy that defines what constitutes a security incident, how incidents should be reported, who is responsible for incident response, escalation procedures, and how incidents are documented. Include a definition of when an incident rises to the level of a reportable breach under HIPAA's Breach Notification Rule.

confluence
2

Establish incident reporting and tracking

Create a mechanism for workforce members to report potential security incidents: a security inbox, a helpdesk ticket category, or a dedicated hotline. Track all reported incidents in a log or ticketing system. Assign ownership for investigation and document findings, response actions, and resolution for each incident.

jira servicenow confluence
3

Implement incident response and mitigation

When an incident is identified, contain it as quickly as possible to prevent further ePHI exposure. This may include disabling compromised accounts, isolating affected systems, or revoking access. After containment, investigate to determine root cause, scope, and whether ePHI was accessed. Implement mitigations to prevent recurrence.

crowdstrike sentinelone microsoft-sentinel
4

Conduct breach risk assessments

For any incident involving potential ePHI access, perform a breach risk assessment to determine whether HIPAA's Breach Notification Rule requires notification to affected individuals and HHS. Document the four-factor risk assessment: the nature and extent of the ePHI involved, who accessed it, whether ePHI was actually acquired or viewed, and the extent to which the risk has been mitigated.

confluence excel