New urgent care buildout
PE-1 procedures require locking server closet, badge readers, and waiting-room workstation orientation before ePHI systems go live.
Physical Protection Policy and Procedures
High Risk
Moderate
Medium Cost
PE-1 requires physical and environmental protection policy and procedures addressing purpose, scope, roles, management commitment, coordination, and compliance, plus procedures to implement the PE family. HIPAA physical safeguards make PE-1 central for clinics, hospitals, data centers, and records rooms — badge access, visitor control, workstation placement, and environmental protections for systems hosting ePHI.
Control Objective
Define policy and procedures that limit physical access to facilities, workstations, and supporting infrastructure where ePHI or ePHI systems can be accessed, damaged, or stolen.
Implementation Guidance
- Publish PE-1 policy covering hospitals, clinics, data centers, IDFs, HIM records areas, and telehealth hardware closets.
- Define badge issuance, visitor escort, and after-hours access rules.
- Require workstation placement and screen privacy expectations in public clinical areas.
- Address environmental controls for critical IT spaces (power, HVAC, water sensors) at a policy level.
- Coordinate with facilities, security officers, and clinical leaders.
- Include vendor/maintenance physical access under PE/MA procedures.
- Review annually and after renovations, mergers, or new clinic openings.
- Align with PE-2/PE-3 access lists and 164.310 facility controls.
Real-World Use Cases
How this control shows up in healthcare and HIPAA-covered environments.
Celebrity patient admission
Physical access policy supports restricted unit access lists and visitor logging coordinated with privacy.
Contractor in MDF
Escort and badge rules under PE-1 prevent unescorted access to switches carrying EHR traffic.
Best Practices
- Role-based badge access with periodic review.
- Visitor logging in sensitive areas.
- Screen privacy in registration and ED triage.
- Environmental monitoring for critical rooms.
- Clinic opening checklist includes PE controls.
- Terminate badges with HR terminations same day.
Common Gaps & Violations
- Propped doors to clinical IDFs.
- Visitors unescorted in EHR nursing stations.
- Workstations facing public waiting areas without privacy screens.
- Terminated staff badges still active.
- No PE policy coverage for offsite clinics.
Required Documentation
- Physical and environmental protection policy (PE-1)
- Facility access procedures
- Visitor/escort standards
- Roles (security, facilities, HIM)
- Policy review records
How to Test & Validate
- Review PE-1 policy scope across all care sites.
- Sample badge access reviews for data rooms.
- Observe workstation placement in a public clinic area.
- Verify visitor logs in a sensitive unit.
- Confirm termination-to-badge disable process.
Audit Considerations
Physical walkthroughs are standard in HIPAA assessments. PE-1 provides the stated rules assessors compare to floor reality.
HIPAA Mapping
How this NIST control supports HIPAA Security Rule expectations.
- 164.310(a) Facility Access Controls — limit physical access to electronic information systems while ensuring authorized access.
- 164.310(b) Workstation Use — functions and attributes of physical surroundings of workstations.
- 164.310(c) Workstation Security — physical safeguards for workstations that access ePHI.
- 164.316 Policies and procedures — document physical safeguard policies.
Compliance Tips
- Add PE checks to new clinic opening gates before EHR go-live.
- Integrate badge disable into the same leaver workflow as EHR access.
- Train front desk staff on visitor rules — they are the real control.
Frequently Asked Questions
Does PE-1 apply to home offices for remote clinicians?
Address telework physical expectations in policy (private space, screen privacy, device storage) even if badge systems do not apply.
Are paper record rooms in scope?
Yes — physical safeguards and privacy requirements cover PHI in any form; include HIM spaces.
How does PE-1 relate to PE-3?
PE-1 is the policy; PE-3 implements physical access control operationally under that policy.
References & Resources
- NIST SP 800-53 Rev. 5 — PE-1
- HIPAA § 164.310
- Related controls: PE-2, PE-3, PE-5, MP-4, PS-4
Related Guidelines
Related controls that commonly accompany PE-1.
Need Help Implementing PE-1?
Our auditors map NIST SP 800-53 controls to your HIPAA Security Rule program — policies, technical evidence, and audit readiness.