Regional network outage
CP-1 procedures activate paper downtime packets, downtime EHR viewing if available, and documented backload rules for ePHI integrity when systems return.
Contingency Planning Policy and Procedures
Critical Risk
Moderate
Low Cost
CP-1 requires contingency planning policy and procedures addressing purpose, scope, roles, management commitment, coordination, and compliance, plus procedures to implement the Contingency Planning family. HIPAA contingency planning standards make CP-1 essential: data backup, disaster recovery, and emergency mode operations must be governed so clinicians can deliver care when the EHR or network is down.
Control Objective
Establish policy and procedures that define how the organization prepares for, responds to, and recovers from disruptions affecting systems and processes that handle ePHI and patient care.
Implementation Guidance
- Publish CP-1 policy covering EHR, identity, network, imaging, pharmacy, and revenue-cycle criticality.
- Define RTO/RPO governance owners and approval of downtime procedures.
- Require tested backups, DR plans, and emergency-mode operations for clinical documentation.
- Assign roles: downtime commanders, nursing informatics, HIM, IT DR, and communications.
- Mandate exercises and after-action improvements on a defined cadence.
- Address BA/cloud recovery dependencies and notification expectations.
- Review policy annually and after significant outages or platform changes.
- Align CP-1 with IR-1 when cyber incidents cause contingency activation.
Real-World Use Cases
How this control shows up in healthcare and HIPAA-covered environments.
Backup repository failure
Policy requires alternate restore path testing for EHR databases — not solely primary backup appliances.
Cloud IdP outage
Contingency policy defines break-glass clinical access when SSO fails so ED care continues under controlled emergency accounts.
Best Practices
- Clinical and IT jointly own contingency policy.
- Explicit RTO/RPO for tier-1 clinical systems.
- Regular downtime drills on units.
- Cloud/BA recovery commitments documented.
- After-action tracking.
- Emergency-mode documentation standards for ePHI accuracy.
Common Gaps & Violations
- DR plan exists for data center only; clinics unprepared.
- Backups never restore-tested.
- No emergency-mode operations procedures for charting.
- Policy silent on ransomware recovery.
- BA recovery SLAs unknown to operations.
Required Documentation
- Contingency planning policy (CP-1)
- Roles and activation procedures
- Linkage to backup/DR/emergency-mode standards
- Exercise schedule requirements
- Policy review/approval records
How to Test & Validate
- Confirm CP-1 policy currency and clinical stakeholder input.
- Verify policy requires backup, DR, and emergency mode.
- Sample evidence of exercises per policy cadence.
- Interview unit leader on downtime packet location.
- Review last outage for policy-aligned activation.
Audit Considerations
HIPAA contingency planning is a frequent OCR focus after outages. CP-1 demonstrates executive governance beyond a dusty DR binder.
HIPAA Mapping
How this NIST control supports HIPAA Security Rule expectations.
- 164.308(a)(7) Contingency Plan — data backup, disaster recovery, emergency mode operations, testing, and applications/data criticality.
- 164.310(a)(2)(i) Contingency Operations — facility access for data restoration.
- 164.312(a)(2)(ii) Emergency Access Procedure — technical emergency access during contingency.
- 164.316 Policies and procedures — maintain contingency policy documentation.
Compliance Tips
- Put CP-1 review on the calendar with annual downtime drills.
- Require each clinical service line to confirm downtime procedure ownership.
- Track cloud RTO/RPO in the same register as on-prem systems.
Frequently Asked Questions
Is a backup policy alone enough for CP-1?
No. CP-1 must govern the full contingency family including DR and emergency-mode operations for care delivery.
Do ambulatory clinics need the same CP-1?
Policy should be enterprise-wide with scaled procedures; clinics still need downtime and recovery expectations.
How does CP-1 relate to CP-2?
CP-1 is policy/procedures; CP-2 is the contingency plan content developed under that policy.
References & Resources
- NIST SP 800-53 Rev. 5 — CP-1
- NIST SP 800-34
- HIPAA § 164.308(a)(7)
- Related controls: CP-2, CP-4, CP-6, CP-7, IR-4
Related Guidelines
Related controls that commonly accompany CP-1.
Need Help Implementing CP-1?
Our auditors map NIST SP 800-53 controls to your HIPAA Security Rule program — policies, technical evidence, and audit readiness.