Develop and implement comprehensive evaluation procedures including:
• Regular security assessments and evaluations
• Technical evaluation of security controls
• Non-technical evaluation of policies and procedures
• Environmental change impact assessments
• Operational change impact assessments
• Evaluation documentation and reporting
• Remediation planning and tracking
Key components:
- Periodic security evaluations
- Technical control assessments
- Policy and procedure reviews
- Change impact assessments
- Documentation of evaluation results
- Remediation planning and tracking
Evaluation
High Risk
Moderate Implementation
Medium Cost
Perform a periodic technical and non-technical evaluation, based initially upon the standards implemented under this rule and subsequently, in response to environmental or operational changes affecting the security of ePHI.
Implementation Guidance
Required Documentation
• Evaluation procedures and schedule
• Technical evaluation criteria and methods
• Non-technical evaluation criteria and methods
• Environmental change assessment procedures
• Operational change assessment procedures
• Evaluation documentation templates
• Remediation planning procedures
• Evaluation reporting procedures
• Technical evaluation criteria and methods
• Non-technical evaluation criteria and methods
• Environmental change assessment procedures
• Operational change assessment procedures
• Evaluation documentation templates
• Remediation planning procedures
• Evaluation reporting procedures
Best Practices
• Conduct regular security evaluations
• Use standardized evaluation criteria
• Document all evaluation results
• Assess impact of all changes
• Develop remediation plans
• Track remediation progress
• Regular reporting to management
• Continuous improvement of evaluation processes
• Use standardized evaluation criteria
• Document all evaluation results
• Assess impact of all changes
• Develop remediation plans
• Track remediation progress
• Regular reporting to management
• Continuous improvement of evaluation processes
Common Violations
• Lack of regular security evaluations
• Inadequate technical control assessments
• Insufficient policy and procedure reviews
• Failure to assess impact of changes
• Inadequate documentation of evaluations
• Lack of remediation planning
• Insufficient evaluation reporting
• Inadequate technical control assessments
• Insufficient policy and procedure reviews
• Failure to assess impact of changes
• Inadequate documentation of evaluations
• Lack of remediation planning
• Insufficient evaluation reporting
Testing Procedures
• Review evaluation procedures and schedule
• Verify technical evaluation methods
• Test non-technical evaluation processes
• Review change impact assessment procedures
• Verify evaluation documentation
• Test remediation planning procedures
• Review evaluation reporting
• Conduct evaluation exercises
• Verify technical evaluation methods
• Test non-technical evaluation processes
• Review change impact assessment procedures
• Verify evaluation documentation
• Test remediation planning procedures
• Review evaluation reporting
• Conduct evaluation exercises
Audit Considerations
• Evaluation procedures and schedule
• Technical evaluation methods and results
• Non-technical evaluation processes
• Change impact assessments
• Evaluation documentation
• Remediation planning and tracking
• Evaluation reporting
• Continuous improvement processes
• Technical evaluation methods and results
• Non-technical evaluation processes
• Change impact assessments
• Evaluation documentation
• Remediation planning and tracking
• Evaluation reporting
• Continuous improvement processes
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)(5) - Security Incident Procedures
164.308(a)(6) - Contingency Plan
164.312(a)(2) - Audit Controls
164.308(a)(5) - Security Incident Procedures
164.308(a)(6) - Contingency Plan
164.312(a)(2) - Audit Controls