Develop and implement comprehensive security incident procedures including:
• Incident detection and reporting procedures
• Incident response team roles and responsibilities
• Incident classification and prioritization
• Incident containment and mitigation procedures
• Incident investigation and analysis procedures
• Incident documentation and reporting requirements
• Post-incident review and improvement procedures
Key components:
- Incident response plan
- Incident response team
- Incident detection and reporting
- Incident classification system
- Incident containment procedures
- Incident documentation requirements
Security Incident Procedures
Critical Risk
Complex Implementation
High Cost
Implement policies and procedures to address security incidents.
Implementation Guidance
Required Documentation
• Security incident response plan
• Incident response team roles and responsibilities
• Incident detection and reporting procedures
• Incident classification and prioritization procedures
• Incident containment and mitigation procedures
• Incident investigation and analysis procedures
• Incident documentation and reporting requirements
• Post-incident review procedures
• Incident response team roles and responsibilities
• Incident detection and reporting procedures
• Incident classification and prioritization procedures
• Incident containment and mitigation procedures
• Incident investigation and analysis procedures
• Incident documentation and reporting requirements
• Post-incident review procedures
Best Practices
• Develop comprehensive incident response plan
• Establish trained incident response team
• Implement effective incident detection and reporting
• Use clear incident classification system
• Develop effective containment procedures
• Document all incident activities
• Conduct regular post-incident reviews
• Regular testing and updating of procedures
• Establish trained incident response team
• Implement effective incident detection and reporting
• Use clear incident classification system
• Develop effective containment procedures
• Document all incident activities
• Conduct regular post-incident reviews
• Regular testing and updating of procedures
Common Violations
• Lack of security incident response plan
• Inadequate incident detection and reporting procedures
• Insufficient incident response team training
• Poor incident classification and prioritization
• Inadequate incident containment procedures
• Insufficient incident documentation
• Lack of post-incident review and improvement
• Inadequate incident detection and reporting procedures
• Insufficient incident response team training
• Poor incident classification and prioritization
• Inadequate incident containment procedures
• Insufficient incident documentation
• Lack of post-incident review and improvement
Testing Procedures
• Review security incident response plan
• Test incident detection and reporting procedures
• Verify incident response team training
• Test incident classification and prioritization
• Review incident containment procedures
• Verify incident documentation requirements
• Test post-incident review procedures
• Conduct incident response exercises
• Test incident detection and reporting procedures
• Verify incident response team training
• Test incident classification and prioritization
• Review incident containment procedures
• Verify incident documentation requirements
• Test post-incident review procedures
• Conduct incident response exercises
Audit Considerations
• Security incident response plan
• Incident response team composition and training
• Incident detection and reporting procedures
• Incident classification and prioritization
• Incident containment and mitigation procedures
• Incident documentation and reporting
• Post-incident review and improvement
• Regular testing and updating of procedures
• Incident response team composition and training
• Incident detection and reporting procedures
• Incident classification and prioritization
• Incident containment and mitigation procedures
• Incident documentation and reporting
• Post-incident review and improvement
• Regular testing and updating of 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
164.308(a)(1) - Security Officer
164.308(a)(4) - Security Awareness and Training
164.308(a)(6) - Contingency Plan
164.312(a)(2) - Audit Controls
164.308(a)(4) - Security Awareness and Training
164.308(a)(6) - Contingency Plan
164.312(a)(2) - Audit Controls