Custodians
High Risk
Moderate
Medium Cost
MP-5(3) (Custodians) enhances base MP-5 within the NIST Media Protection family. Base MP-5 sets the foundational expectation; this enhancement adds specificity: Employ an identified custodian during transport of system media outside of controlled areas. Identified custodians provide organizations with specific points of contact during the media transport process and facilitate individual accountability. Custodial responsibilities can be . Covered entities and business associates apply it to labeling, storage, transport, sanitization, and destruction of digital and paper media containing ePHI.
Control Objective
Implement Custodians so organization-defined media protection safeguards operate consistently on systems and networks that handle ePHI, with measurable evidence for HIPAA and NIST assessments.
Implementation Guidance
- Map MP-5(3) to systems in scope (EHR, imaging, lab, pharmacy, billing, identity, backups, and BA connections).\n2. Translate “Custodians” into technical settings, procedures, or architecture patterns owned by named roles.\n3. Prefer enforceable controls (config, automation, mediation) over awareness-only measures where feasible.\n4. Integrate with change, incident, and downtime processes so clinical operations are not surprised.\n5. Log and retain evidence of operation (tickets, configs, test results) aligned to audit needs.\n6. Include vendors/BAs in contracts and connection standards when they touch the control surface.\n7. Test after major EHR, network, or cloud changes — upgrades often reset protections.\n8. Review exceptions at least quarterly; expire “temporary” holes that expose ePHI paths.
Real-World Use Cases
How this control shows up in healthcare and HIPAA-covered environments.
Best Practices
- Name an owner for MP-5(3) in the SSP control matrix.\n- Favor system enforcement on ePHI paths over informal email approval.\n- Measure coverage: percent of in-scope clinical systems where the enhancement operates.\n- Review exceptions quarterly with security and clinical informatics.\n- Feed relevant events to SIEM with a named use case.\n- Keep a one-page evidence pack (config + sample log + last test) ready for assessors.
Common Gaps & Violations
- Policy cites MP-5(3) but production EHR/network paths show no enforcement of custodians.\n- Permanent exceptions with no expiry for vendors or “special” clinics.\n- Control implemented only on corporate IT — clinical devices and interfaces omitted.\n- No logs or test records; reliance on tribal knowledge.\n- Major upgrade silently disabled the enhancement.
Required Documentation
- Procedure/standard for Custodians (MP-5(3))\n- Architecture or configuration baselines showing enforcement points\n- Exception register with owners and expiry\n- Sample logs, alerts, or test results\n- Training or runbook references for clinical/IT operators
How to Test & Validate
- Attempt a prohibited or out-of-policy action related to custodians; confirm block, alert, or required workflow.\n2. Complete an authorized clinical/IT path; confirm success and logging.\n3. Sample open exceptions for approval and expiry.\n4. Verify at least one EHR-adjacent and one BA/vendor path are in scope.\n5. Confirm evidence retained for the last 90 days (or per policy).
Audit Considerations
Assessors look for operating evidence of Custodians on systems touching ePHI — configs, logs, restore/DR artifacts, or failed-test results — not only a policy paragraph referencing MP-5(3).
HIPAA Mapping
How this NIST control supports HIPAA Security Rule expectations.
- 164.310(d)(1) Device and Media Controls — govern receipt, removal, and disposal of media with ePHI.\n- 164.310(d)(2)(i) Disposal — implement policies for final disposition of ePHI and/or hardware.\n- 164.310(d)(2)(ii) Media Re-use — remove ePHI before media reuse.\n- 164.312(a)(2)(iv) Encryption and Decryption — encrypt ePHI on portable media where reasonable.
Compliance Tips
- List MP-5(3) explicitly in the system security plan with system inventory references.\n- Prioritize emergency department, inpatient EHR, and remote access paths first.\n- Bundle evidence with related HIPAA evaluation, integrity, or workforce-security narratives where they overlap.
References & Resources
- NIST SP 800-53 Rev. 5 — MP-5(3)\n- Related controls: MP-5
Related Guidelines
Related controls that commonly accompany MP-5(3).
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