HIPAA Security Rule Compliance Services

Administrative safeguards represent over half of the Security Rule's requirements and establish the management framework for your entire security program. We implement the security management process including risk analysis, risk management, sanction policy, and information system activity review. We designate your Security Officer (or serve as your virtual Security Officer), develop workforce security procedures including authorization supervision, workforce clearance, and termination procedures, and establish information access management controls including access authorization, access establishment, and access modification procedures.

We also develop your security awareness and training program, establish security incident procedures for identifying, reporting, and responding to security incidents, develop contingency planning including data backup, disaster recovery, emergency mode operations, testing and revision, and create policies governing evaluation, business associate agreements, and ongoing compliance assessment. Every administrative safeguard is documented with specific procedures, designated responsible parties, and review schedules.

Physical safeguards protect the physical infrastructure, facilities, and equipment that house ePHI. We assess and implement facility access controls including contingency operations procedures, facility security plans, access control and validation procedures, and maintenance records documentation. For workstation use and security, we develop policies governing the physical environment and operational use of workstations and mobile devices that access ePHI, including screen positioning, automatic lock timeouts, and restrictions on workstation placement in public-facing areas.

Device and media controls address the movement of hardware and electronic media containing ePHI into, out of, and within your facilities. We implement disposal procedures that ensure ePHI is properly destroyed before hardware is repurposed or discarded, media re-use protocols, accountability tracking for hardware and media movement, and data backup and storage procedures. For healthcare organizations with multiple locations, we establish consistent physical safeguard standards across all facilities while accounting for the unique physical characteristics of each site.

Technical safeguards are the technology-based controls that protect ePHI in your information systems. We implement access controls including unique user identification (eliminating shared accounts), emergency access procedures, automatic logoff configurations, and encryption and decryption mechanisms for ePHI at rest. Audit controls are configured across all systems to record and examine activity in information systems that contain or use ePHI — we deploy centralized logging, SIEM integration, and automated alerting for suspicious access patterns.

Integrity controls protect ePHI from improper alteration or destruction through mechanisms such as hashing, digital signatures, and database integrity verification. Person or entity authentication ensures that users are who they claim to be through multi-factor authentication, certificate-based authentication, and other strong authentication mechanisms. Transmission security protects ePHI during electronic transmission through encryption protocols (TLS 1.2+, VPN tunnels, encrypted email) and integrity controls that verify data has not been altered during transit. We implement these controls across your entire ePHI ecosystem including EHR systems, email, cloud services, remote access, and mobile devices.

Our HIPAA risk analysis follows the methodology outlined in NIST SP 800-30 and NIST SP 800-66 (the HHS-recommended guide for HIPAA Security Rule implementation). We identify the scope of the analysis covering all ePHI systems, catalog data flows showing where ePHI is created, received, maintained, and transmitted, identify threats (natural, human, and environmental) and vulnerabilities in current controls, assess the likelihood and impact of potential compromises, and determine risk levels for each identified threat-vulnerability pair.

Risk management follows directly from the risk analysis. We develop a risk management plan that documents specific measures to reduce each identified risk to a reasonable and appropriate level. Measures include implementing new technical controls, strengthening existing controls, developing policies and procedures, conducting training, modifying workflows, and accepting residual risk where appropriate with documented justification. The risk analysis and risk management plan together form the compliance documentation that OCR requests first in any investigation — organizations that cannot produce these documents face immediate enforcement exposure.

The Security Rule requires security awareness and training for all workforce members, with specific implementation specifications for security reminders, protection from malicious software, login monitoring, and password management. We develop and deliver comprehensive training programs that cover these required topics plus practical security skills including phishing recognition, social engineering awareness, mobile device security, secure data handling, and incident reporting procedures.

Training is role-based — clinical staff receive training focused on EHR security and patient data handling, administrative staff focus on email security and access management, IT staff receive deeper technical security training, and leadership receives governance-focused content on compliance obligations and risk management. We conduct simulated phishing campaigns, track training completion and assessment scores, and provide ongoing security awareness communications that keep security top of mind between formal training sessions.

The Security Rule requires a comprehensive contingency plan that ensures the availability of ePHI during and after emergencies. We develop your data backup plan establishing procedures for creating and maintaining retrievable exact copies of ePHI, your disaster recovery plan documenting procedures to restore systems and data after an emergency, your emergency mode operations plan enabling critical processes to continue protecting ePHI during emergencies, and testing and revision procedures to ensure plans are tested regularly and updated based on test results.

Our contingency planning extends beyond documentation to actual implementation. We configure and verify backup systems, establish recovery time objectives (RTOs) and recovery point objectives (RPOs), conduct tabletop exercises and simulated disaster scenarios, and validate that recovery procedures actually work under realistic conditions. For healthcare organizations, maintaining access to patient records during emergencies is not merely a compliance requirement — it is a patient safety imperative. We ensure your contingency plans support both compliance and clinical continuity.

Security Rule compliance is not a point-in-time achievement — it requires ongoing vigilance, monitoring, and adaptation. We provide continuous compliance monitoring services that include real-time security event monitoring through SIEM platforms, regular vulnerability scanning and patch management, periodic access review and privilege auditing, ongoing risk assessment updates as your environment changes, policy and procedure reviews triggered by regulatory updates or operational changes, and annual comprehensive risk analysis refreshes.

Our monitoring program generates compliance dashboards and reports that give your leadership visibility into your Security Rule compliance posture at any point in time. When gaps are identified — whether from environmental changes, new threats, regulatory updates, or findings from monitoring activities — we provide remediation guidance and implementation support to close them promptly. This continuous approach ensures your organization maintains compliance between formal assessments and can demonstrate ongoing compliance to OCR during investigations or reviews.