Have you identified areas of risk?
Explanation
Guidance
Refer to HIPAA regulations documentation for supplemental guidance in this section.
Example Responses
Example Response 1
Yes, our organization conducts comprehensive risk assessments annually using the NIST SP 800-30 methodology, with the most recent assessment completed in March 2023 We have identified several key risk areas including: (1) potential vulnerabilities in our remote access systems for clinical staff, (2) third-party vendor access to systems containing PHI, (3) backup and disaster recovery processes for critical PHI repositories, and (4) physical security controls at our secondary data center Each identified risk has been documented in our risk register with assigned risk ratings, and we have implemented a formal risk management plan with designated owners and timelines for remediation Our HIPAA Security Officer reviews the status of risk remediation activities quarterly with executive leadership.
Example Response 2
Yes, we have identified areas of risk through our biannual risk assessment process Our most recent assessment was completed in November 2022 using the HHS/ONC Security Risk Assessment Tool Key risk areas identified include: (1) encryption of PHI at rest on certain legacy systems, (2) access control management for departing employees, (3) potential gaps in our Business Associate Agreement process, and (4) inconsistent audit logging across all systems containing PHI We maintain a risk treatment plan that categorizes risks by severity and includes mitigation strategies, responsible parties, and target completion dates Our compliance committee reviews progress on risk remediation monthly, and our full risk assessment documentation is available upon request with appropriate NDAs in place.
Example Response 3
No, we have not yet conducted a formal risk assessment specifically focused on HIPAA compliance As a relatively new business associate that only began handling PHI six months ago, we are still developing our compliance program We have engaged a healthcare compliance consulting firm to help us conduct our first comprehensive risk assessment next month In the interim, we have implemented baseline security controls including encryption of PHI, access controls, and staff training on HIPAA requirements We recognize this is a significant gap in our compliance program and have prioritized completing the risk assessment and developing a corresponding risk management plan by the end of Q3 this year.
Context
- Tab
- Case-Specific
- Category
- HIPAA Compliance

