Develop and implement a comprehensive security awareness and training program including:
• Initial security training for new employees
• Ongoing security awareness training for all workforce members
• Role-specific security training
• Security incident response training
• Regular security updates and communications
• Training effectiveness evaluation
Key components:
- Security awareness training program
- Role-based security training
- Regular security updates
- Training documentation and records
- Training effectiveness measurement
- Incident response training
Security Awareness and Training
High Risk
Moderate Implementation
Medium Cost
Implement a security awareness and training program for all members of the workforce (including management).
Implementation Guidance
Required Documentation
• Security awareness and training program
• Training materials and curricula
• Training schedules and records
• Role-specific training programs
• Training effectiveness evaluation procedures
• Incident response training materials
• Regular security update procedures
• Training materials and curricula
• Training schedules and records
• Role-specific training programs
• Training effectiveness evaluation procedures
• Incident response training materials
• Regular security update procedures
Best Practices
• Develop comprehensive training program
• Provide role-specific training
• Regular security awareness updates
• Document all training activities
• Evaluate training effectiveness
• Use interactive training methods
• Provide ongoing security communications
• Provide role-specific training
• Regular security awareness updates
• Document all training activities
• Evaluate training effectiveness
• Use interactive training methods
• Provide ongoing security communications
Common Violations
• Lack of security awareness training program
• Inadequate training for workforce members
• Failure to provide role-specific training
• Insufficient training documentation
• Lack of training effectiveness evaluation
• Failure to provide regular security updates
• Inadequate training for workforce members
• Failure to provide role-specific training
• Insufficient training documentation
• Lack of training effectiveness evaluation
• Failure to provide regular security updates
Testing Procedures
• Review security awareness and training program
• Verify training materials and curricula
• Test training delivery methods
• Review training records and documentation
• Evaluate training effectiveness
• Test incident response training
• Verify regular security updates
• Verify training materials and curricula
• Test training delivery methods
• Review training records and documentation
• Evaluate training effectiveness
• Test incident response training
• Verify regular security updates
Audit Considerations
• Security awareness and training program
• Training materials and delivery methods
• Training records and documentation
• Role-specific training programs
• Training effectiveness evaluation
• Incident response training
• Regular security updates
• Training materials and delivery methods
• Training records and documentation
• Role-specific training programs
• Training effectiveness evaluation
• Incident response training
• Regular security updates
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
164.308(a)(1) - Security Officer
164.308(a)(2) - Workforce Security
164.308(a)(5) - Security Incident Procedures
164.312(a)(1) - Access Control
164.308(a)(2) - Workforce Security
164.308(a)(5) - Security Incident Procedures
164.312(a)(1) - Access Control