Develop comprehensive facility access control policies including:
• Physical access controls for facilities housing ePHI systems
• Visitor access procedures and controls
• Employee access procedures and controls
• Maintenance and service personnel access procedures
• Emergency access procedures
• Monitoring and logging of physical access
Key components:
- Contingency operations procedures
- Facility security plan
- Access control and validation procedures
- Maintenance records
- Physical access monitoring and logging
Facility Access Controls
High Risk
Moderate Implementation
High Cost
Implement policies and procedures to limit physical access to electronic information systems and the facility or facilities in which they are housed, while ensuring that properly authorized access is allowed.
Implementation Guidance
Required Documentation
• Facility access control policies
• Contingency operations procedures
• Facility security plan
• Access control and validation procedures
• Maintenance records and procedures
• Physical access monitoring and logging procedures
• Visitor access procedures
• Emergency access procedures
• Contingency operations procedures
• Facility security plan
• Access control and validation procedures
• Maintenance records and procedures
• Physical access monitoring and logging procedures
• Visitor access procedures
• Emergency access procedures
Best Practices
• Implement layered physical security
• Use access control systems and monitoring
• Regular review of access permissions
• Document all access control procedures
• Train workforce on physical security
• Regular testing of access controls
• Implement emergency access procedures
• Use access control systems and monitoring
• Regular review of access permissions
• Document all access control procedures
• Train workforce on physical security
• Regular testing of access controls
• Implement emergency access procedures
Common Violations
• Inadequate physical access controls
• Lack of visitor access procedures
• Insufficient monitoring of physical access
• Inadequate maintenance procedures
• Lack of emergency access procedures
• Insufficient documentation of access controls
• Lack of visitor access procedures
• Insufficient monitoring of physical access
• Inadequate maintenance procedures
• Lack of emergency access procedures
• Insufficient documentation of access controls
Testing Procedures
• Review facility access control policies
• Test physical access controls
• Verify visitor access procedures
• Review maintenance procedures
• Test emergency access procedures
• Verify monitoring and logging capabilities
• Review documentation of access controls
• Test physical access controls
• Verify visitor access procedures
• Review maintenance procedures
• Test emergency access procedures
• Verify monitoring and logging capabilities
• Review documentation of access controls
Audit Considerations
• Facility access control policies and procedures
• Physical access controls and monitoring
• Visitor access procedures
• Maintenance procedures and records
• Emergency access procedures
• Documentation of access controls
• Regular review and update procedures
• Physical access controls and monitoring
• Visitor access procedures
• Maintenance procedures and records
• Emergency access procedures
• Documentation of access controls
• Regular review and update procedures
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
Download ChecklistExpert 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
164.310(a)(2) - Workstation Use
164.310(a)(2)(ii) - Workstation Controls
164.310(b) - Media Controls
164.310(c) - Device and Media Controls
164.310(a)(2)(ii) - Workstation Controls
164.310(b) - Media Controls
164.310(c) - Device and Media Controls