164.308(a)(6) Administrative Safeguards

Contingency Plan

Critical Risk Complex Implementation High Cost

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 ePHI.

Implementation Guidance

Develop and implement comprehensive contingency planning including:
• Data backup plan with regular backups and testing
• Disaster recovery plan with recovery time objectives
• Emergency mode operation plan for critical functions
• Testing and revision procedures for all plans
• Applications and data criticality analysis
• Emergency access procedures
• Communication plans for emergencies

Key components:
- Data backup and recovery procedures
- Disaster recovery planning
- Emergency mode operations
- Business continuity planning
- Regular testing and updating of plans
- Critical system identification

Required Documentation

• Contingency plan document
• Data backup plan and procedures
• Disaster recovery plan
• Emergency mode operation plan
• Testing and revision procedures
• Applications and data criticality analysis
• Emergency access procedures
• Communication plans

Best Practices

• Develop comprehensive contingency planning
• Implement regular data backup procedures
• Create detailed disaster recovery plans
• Establish emergency mode operations
• Regular testing and updating of plans
• Document all critical systems and applications
• Establish clear communication procedures
• Coordinate with external service providers

Common Violations

• Lack of comprehensive contingency plan
• Inadequate data backup procedures
• Insufficient disaster recovery planning
• No emergency mode operation plan
• Failure to test contingency plans regularly
• Inadequate documentation of critical systems
• Insufficient emergency communication procedures

Testing Procedures

• Review contingency plan documentation
• Test data backup and recovery procedures
• Verify disaster recovery capabilities
• Test emergency mode operations
• Review testing and revision procedures
• Verify critical system documentation
• Test emergency communication procedures
• Conduct tabletop exercises

Audit Considerations

• Contingency plan completeness and accuracy
• Data backup procedures and testing
• Disaster recovery capabilities
• Emergency mode operation procedures
• Regular testing and updating of plans
• Critical system documentation
• Emergency communication procedures
• Coordination with external parties

NIST Cybersecurity Framework Alignment

This HIPAA control aligns with the following NIST Cybersecurity Framework functions and controls:

Identify (ID)

  • ID.AM-1: Physical devices and systems within the organization are inventoried
  • ID.AM-2: Software platforms and applications within the organization are inventoried
  • ID.AM-3: Organizational communication and data flows are mapped

Protect (PR)

  • PR.AC-1: Identities and credentials are issued, managed, verified, revoked, and audited
  • PR.AC-3: Remote access is managed
  • PR.DS-1: Data-at-rest is protected
  • PR.DS-2: Data-in-transit is protected

Detect (DE)

  • DE.AE-1: A baseline of network operations and expected data flows is established
  • DE.CM-1: The network is monitored to detect potential cybersecurity events
  • DE.CM-3: Personnel activity is monitored to detect potential cybersecurity events

Respond (RS)

  • RS.CO-1: Personnel know their roles and order of operations when a response is needed
  • RS.CO-2: Incidents are reported consistent with established criteria
  • RS.AN-1: Notifications from detection systems are investigated

Recover (RC)

  • RC.RP-1: Recovery plan is executed during or after a cybersecurity incident
  • RC.IM-1: Recovery plans incorporate lessons learned
  • RC.CO-1: Public relations are managed

Note: This mapping provides a general alignment between HIPAA controls and NIST Framework functions. Specific implementation may vary based on your organization's risk profile and compliance requirements.

Implementation Templates & Checklists

Download our expert-developed templates and checklists to implement this control effectively:

Implementation Checklist

Step-by-step checklist to ensure complete implementation of this control

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Policy Template

Ready-to-customize policy template for this specific control

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Risk Assessment Form

Comprehensive risk assessment form for this control

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Training Materials

Staff training materials and awareness resources

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Expert Implementation Recommendations

Based on our experience with 500+ healthcare organizations, here are our expert recommendations for implementing this control:

High Priority

Start with Risk Assessment

Conduct a comprehensive risk assessment to identify specific vulnerabilities and threats related to this control. This will help prioritize implementation efforts and allocate resources effectively.

  • Identify all systems and data covered by this control
  • Assess current security measures and gaps
  • Evaluate potential impact of security incidents
  • Document findings and remediation priorities
Medium Priority

Develop Comprehensive Policies

Create detailed policies and procedures that address all aspects of this control. Ensure policies are specific, actionable, and aligned with your organization's risk profile.

  • Define roles and responsibilities clearly
  • Establish approval workflows and escalation procedures
  • Include specific technical requirements and standards
  • Regular review and update schedules
Low Priority

Implement Monitoring and Testing

Establish ongoing monitoring and testing procedures to ensure the control remains effective over time. Regular testing helps identify new vulnerabilities and compliance gaps.

  • Automated monitoring where possible
  • Regular manual testing and validation
  • Incident response procedures
  • Continuous improvement processes

Recommended Implementation Timeline

1

Week 1-2: Assessment & Planning

Conduct risk assessment and develop implementation plan

2

Week 3-4: Policy Development

Create and review policies and procedures

3

Week 5-8: Implementation

Deploy technical controls and train staff

4

Week 9-10: Testing & Validation

Test controls and validate compliance

Related Controls

164.308(a)(1) - Security Officer
164.308(a)(5) - Security Incident Procedures
164.310(a)(1) - Facility Access Controls
164.312(a)(2) - Audit Controls

Quick Facts

Control ID: 164.308(a)(6)
Category: Administrative Safeguards
Subcategory: Security Management Process
Risk Level: Critical
Difficulty: Complex
Cost: High
Timeframe: 3-6 months
Views: 54
Last Updated: Nov 22, 2025

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Additional Resources

• NIST SP 800-66 Rev. 2: Contingency Plan Guidance
• HHS Contingency Plan Guidance
• Business Continuity Planning Guide
• Disaster Recovery Best Practices
• Emergency Response Procedures Template

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