HIPA-09

Have you taken actions to mitigate the identified risks?

Explanation

This question is asking whether your organization has implemented specific measures to address risks identified during your HIPAA risk assessment process. Under HIPAA, covered entities and business associates must conduct regular risk analyses to identify potential vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (ePHI). However, simply identifying risks is not enough - the Security Rule requires organizations to implement security measures to reduce these risks to a 'reasonable and appropriate' level. The question is being asked because HIPAA compliance requires not just risk identification but also risk mitigation. Assessors want to verify that you have an active risk management program that includes implementing controls to address identified vulnerabilities. This demonstrates your commitment to protecting sensitive health information and shows regulatory compliance. To best answer this question, you should: 1. Confirm that you have implemented specific mitigation measures for identified risks 2. Provide examples of risks you've identified and the corresponding controls implemented 3. Explain your risk management process, including how you prioritize risks and determine appropriate mitigations 4. Mention documentation you maintain regarding risk mitigation activities 5. Describe your process for evaluating the effectiveness of implemented controls

Guidance

Refer to HIPAA regulations documentation for supplemental guidance in this section.

Example Responses

Example Response 1

Yes, we have implemented comprehensive mitigation measures for all identified risks from our HIPAA risk assessment Our risk management process includes quarterly reviews where we prioritize risks based on potential impact and likelihood For each identified risk, we develop and implement specific controls For example, we identified a risk of unauthorized access to ePHI through our patient portal, so we implemented multi-factor authentication, session timeouts, and enhanced access logging For the risk of data loss, we implemented encrypted backups with regular testing We maintain a risk register that documents each identified risk, the implemented controls, residual risk levels, and verification of control effectiveness Our compliance team conducts quarterly reviews to ensure mitigations remain effective, and we adjust our approach based on these evaluations.

Example Response 2

Yes, our organization has taken specific actions to mitigate all high and medium risks identified in our HIPAA risk assessment We follow a structured risk management framework where each risk is assigned an owner responsible for implementing appropriate controls For example, when we identified risks related to employee handling of PHI, we implemented a comprehensive training program with quarterly refreshers and competency testing To address technical vulnerabilities, we deployed endpoint encryption, implemented a next-generation firewall, and established a vulnerability management program with monthly scanning and remediation timelines We document all mitigation activities in our risk treatment plans, which include implementation dates, responsible parties, and effectiveness metrics Our HIPAA Security Officer reviews these plans quarterly to ensure continued compliance and effectiveness.

Example Response 3

We have identified several risks in our recent HIPAA risk assessment but have not yet implemented comprehensive mitigation measures for all of them Due to resource constraints, we've prioritized addressing only the highest-risk items, such as implementing encryption for our databases containing ePHI and updating our access control policies However, we still have several medium-risk items that remain unaddressed, including updating our disaster recovery procedures and implementing automated log monitoring We have developed a roadmap to address these remaining items over the next 12 months as budget and resources become available In the meantime, we have documented these unmitigated risks in our risk register and have implemented compensating controls where possible We recognize this is a gap in our HIPAA compliance program and are working to resolve it according to our remediation timeline.

Context

Tab: Case-Specific
Category: HIPAA Compliance