Have the relevant policies/plans been tested?
Explanation
Guidance
Refer to HIPAA regulations documentation for supplemental guidance in this section.
Example Responses
Example Response 1
Yes, all HIPAA-relevant policies and plans are tested on a regular schedule Our incident response plan is tested quarterly through tabletop exercises involving our security, IT, compliance, and executive teams Our disaster recovery and business continuity plans are tested annually through full simulations, with the most recent test completed on March 15, 2023 Privacy policies are reviewed semi-annually by our compliance team and tested through mock audits All test results are documented, reviewed by our HIPAA Security Officer, and any identified gaps are addressed through our formal remediation process Evidence of these tests and their outcomes can be provided upon request.
Example Response 2
Yes, we conduct comprehensive testing of our HIPAA-relevant policies and plans Our testing program includes: 1) Annual penetration testing of our systems containing PHI, last completed January 2023; 2) Quarterly incident response simulations with scenarios specifically involving PHI breaches, most recently conducted in April 2023; 3) Bi-annual disaster recovery testing that includes restoration of PHI data from backups, last performed in December 2022; and 4) Annual compliance audits by an independent third party to verify adherence to our privacy policies, with the most recent audit completed in March 2023 All test results are documented in our compliance management system, and any findings are tracked to resolution through our risk management process.
Example Response 3
No, not all of our HIPAA-relevant policies and plans have been formally tested yet While we have comprehensive documentation of our policies, we have only conducted partial testing of our incident response procedures through informal walkthroughs We have not yet performed formal testing of our disaster recovery or business continuity plans as they relate to PHI We recognize this gap in our compliance program and have scheduled comprehensive testing of all HIPAA-relevant policies and plans to begin next quarter We have engaged a third-party security firm to assist with this testing, and we have developed a testing schedule that will ensure all policies are tested by the end of this calendar year In the interim, we have implemented additional monitoring controls to help mitigate risks.
Context
- Tab
- Case-Specific
- Category
- HIPAA Compliance

