164.308(a)(2) Administrative Safeguards

Workforce Security

High Risk Moderate Medium

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

Implementation Resources

Download expert-developed templates and checklists to implement this control:

Quick Facts

Control ID 164.308(a)(2)
Category Administrative Safeguards
Risk Level High
Difficulty Moderate
Est. Cost Medium
Timeframe 2-4 months
Last Updated Mar 1, 2026

Need Help Implementing This Control?

Our certified HIPAA experts can help you implement this control correctly and efficiently.