Designate a qualified individual as the Security Officer with clear responsibilities including:
• Developing and implementing security policies and procedures
• Conducting regular security risk assessments
• Managing security incidents and breaches
• Ensuring workforce training on security policies
• Monitoring compliance with security requirements
• Coordinating with other departments on security matters
The Security Officer should have appropriate authority, resources, and reporting structure to effectively carry out these responsibilities.
Security Officer
High Risk
Moderate Implementation
Medium Cost
A covered entity must designate a security official who is responsible for developing and implementing its security policies and procedures.
Implementation Guidance
Required Documentation
• Security Officer designation letter
• Job description and responsibilities
• Organizational chart showing reporting structure
• Security Officer training records
• Regular review and update procedures
• Job description and responsibilities
• Organizational chart showing reporting structure
• Security Officer training records
• Regular review and update procedures
Best Practices
• Ensure Security Officer has appropriate technical and administrative background
• Establish clear reporting structure to senior management
• Provide ongoing training and professional development
• Document all security-related decisions and actions
• Regular communication with workforce about security matters
• Coordinate with Privacy Officer and other compliance personnel
• Establish clear reporting structure to senior management
• Provide ongoing training and professional development
• Document all security-related decisions and actions
• Regular communication with workforce about security matters
• Coordinate with Privacy Officer and other compliance personnel
Common Violations
• No designated Security Officer
• Security Officer lacks appropriate authority or resources
• Inadequate documentation of Security Officer responsibilities
• Failure to regularly review and update security policies
• Security Officer not properly trained on HIPAA requirements
• Security Officer lacks appropriate authority or resources
• Inadequate documentation of Security Officer responsibilities
• Failure to regularly review and update security policies
• Security Officer not properly trained on HIPAA requirements
Testing Procedures
• Verify Security Officer designation is documented
• Review Security Officer job description and responsibilities
• Confirm Security Officer has appropriate authority and resources
• Test Security Officer knowledge through interviews or assessments
• Review documentation of security policy development and implementation
• Verify regular review and update of security policies
• Review Security Officer job description and responsibilities
• Confirm Security Officer has appropriate authority and resources
• Test Security Officer knowledge through interviews or assessments
• Review documentation of security policy development and implementation
• Verify regular review and update of security policies
Audit Considerations
• Security Officer designation and qualifications
• Documentation of responsibilities and authority
• Evidence of policy development and implementation
• Training records and ongoing education
• Communication with workforce and management
• Coordination with other compliance functions
• Documentation of responsibilities and authority
• Evidence of policy development and implementation
• Training records and ongoing education
• Communication with workforce and management
• Coordination with other compliance functions
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)(2) - Workforce Security
164.308(a)(3) - Information Access Management
164.308(a)(4) - Security Awareness and Training
164.308(a)(5) - Security Incident Procedures
164.308(a)(6) - Contingency Plan
164.308(a)(7) - Evaluation
164.308(a)(3) - Information Access Management
164.308(a)(4) - Security Awareness and Training
164.308(a)(5) - Security Incident Procedures
164.308(a)(6) - Contingency Plan
164.308(a)(7) - Evaluation