§164.308(a)(1)(ii)(A): Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity or business associate.

Audit Inquiry

Does the entity have policies and procedures in place to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of all the electronic protected health information (ePHI) it creates, receives, maintains, or transmits?

Has the entity conducted an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of all the ePHI it creates, receives, maintains, or transmits?

Determine how the entity has implemented the requirements.

Obtain and review risk analysis policies and procedures. Evaluate and determine if written policies and procedures were developed to address the purpose and scope of the risk analysis, workforce member roles and responsibilities, management involvement in risk analysis and how frequently the risk analysis will be reviewed and updated.

Obtain and review the written risk analysis or other record(s) that documents that an accurate and thorough assessment of the risks and vulnerabilities to the confidentiality, integrity, and availability of all ePHI was been conducted. Evaluate and determine whether the risk analysis or other documentation contains:
• A defined scope that identifies all of its systems that create, transmit, maintain, or transmit ePHI
• Details of identified threats and vulnerabilities
• Assessment of current security measures
• Impact and likelihood analysis
• Risk rating

Obtain and review documentation regarding the written risk analysis or other documentation that immediately preceded the current risk analysis or other record, if any. Evaluate and determine if the risk analysis has been reviewed and updated on a periodic basis, in response to changes in the environment and/or operations, security incidents, or occurrence of a significant event.

If there is no prior risk analysis or other record, obtain and review the two (2) most recent written updates to the risk analysis or other record, if any. If the original written risk analysis or other records have not been updated since they were originally conducted and/or drafted, obtain and review an explanation as to the reason why.