EHR patch backlog after vulnerability scan
Critical CVEs enter CA-5 with owners and freeze-window milestones; weekly review shows two items overdue and escalates to CIO.
Plan of Action and Milestones
High Risk
Moderate
Low Cost
CA-5 requires developing a plan of action and milestones (POA&M) for the system to document planned remedial actions to correct weaknesses or deficiencies noted during assessments and to reduce or eliminate known vulnerabilities. For covered entities and BAs, the POA&M is the living bridge between risk analysis findings, audit results, and closed remediation — not a static spreadsheet forgotten after OCR season.
Control Objective
Maintain an actionable, prioritized POA&M that tracks ePHI-related weaknesses from discovery through verified remediation with owners and dates.
Implementation Guidance
- Centralize findings from risk analysis, vulnerability scans, penetration tests, audits, and incidents into one POA&M register.
- Record for each item: description, source, affected systems/ePHI impact, risk rating, owner, milestones, due date, and status.
- Prioritize by patient safety, ePHI exposure, and exploitability — not only by auditor preference.
- Define escalation when milestones slip (e.g., 30/60/90 days).
- Link remediation evidence (tickets, configs, screenshots) to each closed item.
- Review POA&M in security governance meetings at least monthly for High items.
- Separate accepted risks with residual risk approval (CA-6/RA-3) from open remediations.
- Retain historical POA&M for trend analysis and audit sampling.
Real-World Use Cases
How this control shows up in healthcare and HIPAA-covered environments.
OCR-driven risk analysis gaps
Encryption-at-rest exceptions and missing BAAs become POA&M lines with legal and IT co-owners — tracked to closure with evidence.
Pen test finds open RDP on a clinic server
Finding is logged same week; temporary ACL and then permanent remediation milestones close the item before the next CA-8 cycle.
Best Practices
- Single source of truth for remediation.
- Risk-based prioritization tied to ePHI.
- Evidence attached on close.
- Escalation for slipped dates.
- Distinguish accepted risk vs open work.
- Governance visibility for High/Critical.
Common Gaps & Violations
- Findings live only in PDF reports.
- No owners or due dates.
- Items marked closed without verification.
- Accepted risks undocumented.
- POA&M never reviewed between annual audits.
Required Documentation
- POA&M procedure / SOP
- Current POA&M register (exportable)
- Prioritization and escalation criteria
- Sample closed items with evidence
- Meeting minutes showing POA&M review
How to Test & Validate
- Trace three recent assessment findings into the POA&M.
- Verify High items have owners and dates.
- Sample closed items for attached evidence.
- Confirm overdue escalation occurred when dates slipped.
- Check accepted-risk items have approvals.
Audit Considerations
Assessors and OCR investigators look for a living remediation tracker. Static or empty POA&Ms after known findings are high-visibility weaknesses.
HIPAA Mapping
How this NIST control supports HIPAA Security Rule expectations.
- 164.308(a)(1)(ii)(A) Risk Analysis — identified risks must feed managed remediation.
- 164.308(a)(1)(ii)(B) Risk Management — implement security measures to reduce risks to reasonable and appropriate levels.
- 164.308(a)(8) Evaluation — evaluation findings should drive corrective action tracked in POA&M.
- 164.316(b) Documentation — retain documentation of actions and decisions related to remediation.
Compliance Tips
- Import scanner and pen-test exports into the same tool used for risk findings.
- Never close a POA&M item on 'vendor said it is fixed' without independent verify.
- Show POA&M trends (open High over time) to leadership quarterly.
Frequently Asked Questions
Is a GRC ticket queue enough for CA-5?
Yes if it captures milestones, risk, owners, evidence, and is reviewed — the label POA&M matters less than the discipline.
How does CA-5 relate to RA-3?
RA-3 assesses risk; CA-5 tracks planned fixes for residual weaknesses that remain after or instead of immediate treatment.
Do we POA&M every informational finding?
Prioritize; track what matters for ePHI and operations. Document why low items are deferred.
References & Resources
- NIST SP 800-53 Rev. 5 — CA-5
- NIST SP 800-37 RMF (POA&M in authorize/monitor)
- Related controls: CA-2, CA-7, CA-8, RA-3, SI-2
Related Guidelines
Related controls that commonly accompany CA-5.
Need Help Implementing CA-5?
Our auditors map NIST SP 800-53 controls to your HIPAA Security Rule program — policies, technical evidence, and audit readiness.