164.308(a)(2) Administrative Safeguards

Workforce Security

High Risk Moderate Implementation Medium Cost

Implement policies and procedures to ensure that all members of the workforce have appropriate access to electronic protected health information (ePHI) and to prevent those workforce members who do not have access from obtaining access to ePHI.

Implementation Guidance

Develop and implement workforce security policies including:
• Background checks and screening procedures for new hires
• Access authorization procedures based on job functions
• Regular review and update of access permissions
• Procedures for terminating access when employees leave
• Monitoring of workforce access to ePHI
• Training on workforce security policies

Key components:
- Pre-employment screening and background checks
- Role-based access control (RBAC)
- Regular access reviews and recertification
- Proper termination procedures
- Ongoing monitoring and auditing

Required Documentation

• Workforce security policies and procedures
• Background check procedures and forms
• Access authorization procedures
• Job function descriptions and access requirements
• Access review and recertification procedures
• Termination procedures and checklists
• Training records and materials

Best Practices

• Implement comprehensive background check procedures
• Use role-based access control (RBAC) principles
• Conduct regular access reviews and recertification
• Implement proper termination procedures
• Monitor and audit workforce access regularly
• Provide ongoing security training
• Document all access decisions and changes

Common Violations

• Inadequate background checks or screening
• Failure to implement role-based access control
• Lack of regular access reviews
• Inadequate termination procedures
• Insufficient monitoring of workforce access
• Failure to train workforce on security policies

Testing Procedures

• Review workforce security policies and procedures
• Verify background check procedures are implemented
• Test access authorization processes
• Review access review and recertification procedures
• Verify termination procedures are followed
• Test monitoring and auditing capabilities
• Review training records and materials

Audit Considerations

• Workforce security policies and procedures
• Background check procedures and records
• Access authorization and review processes
• Termination procedures and documentation
• Monitoring and auditing capabilities
• Training records and effectiveness

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

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Implementation Checklist

Step-by-step checklist to ensure complete implementation of this control

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Policy Template

Ready-to-customize policy template for this specific control

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Risk Assessment Form

Comprehensive risk assessment form for this control

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Training Materials

Staff training materials and awareness resources

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Expert 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)(3) - Information Access Management
164.308(a)(4) - Security Awareness and Training
164.312(a)(1) - Access Control

Quick Facts

Control ID: 164.308(a)(2)
Category: Administrative Safeguards
Subcategory: Security Management Process
Risk Level: High
Difficulty: Moderate
Cost: Medium
Timeframe: 2-4 months
Views: 48
Last Updated: Nov 22, 2025

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Additional Resources

• NIST SP 800-66 Rev. 2: Workforce Security Guidance
• HHS Workforce Security Guidance
• Background Check Best Practices
• Role-Based Access Control Implementation Guide
• Termination Procedures Checklist

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164.308(a)(1) High

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