HIPAA §164.308(a)(1) - Security Management Process

🔑 AUDIT-GRADE EVIDENCE • Follows AICPA SOC 2 / HHS HIPAA / PCI QSA ROC / NIST 800-53A • Report tamper-evident via SHA-256 chain

1. CONTROL IDENTIFICATION

FrameworkHIPAA Security Rule
Control ID§164.308(a)(1)
Control FamilyAdministrative Safeguards > Security Management
Control NameSecurity Management Process
StatusPARTIALLY IMPLEMENTED
Assessment Date2026-04-19T02:25:35.202960+00:00
AssessorTITAN AI Scanner v2.0 (CONDUCTOR + BASTION + SCOUT + COMPLY + SAGE)
Environment ScopeAzure: Pay-As-You-Go (prod) (4f29d094-1079-44c9-acb0-4d73a7a2dd34)
Report ID9ba0b9eec923e87a4ac18f41c49c3c01d1bce02a6c4fa74b6ca45428064383aa

2. REGULATORY TEXT

Standard: Security management process. Implement policies and procedures to prevent, detect, contain, and correct security violations.

Source: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C/section-164.308

3. IMPLEMENTATION SPECIFICATIONS

Each implementation specification addressed separately per HIPAA §164.306(d) / NIST 800-53A assessment methodology.

164.308(a)(1)(ii)(A) REQUIRED Risk Analysis PARTIALLY IMPLEMENTED

Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information.

Evidence: #A1, #A2
164.308(a)(1)(ii)(B) REQUIRED Risk Management PARTIALLY IMPLEMENTED

Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level.

Evidence: #A1, #A2
164.308(a)(1)(ii)(C) REQUIRED Sanction Policy PARTIALLY IMPLEMENTED

Apply appropriate sanctions against workforce members who fail to comply with the security policies and procedures of the covered entity.

Evidence: #A1, #A2
164.308(a)(1)(ii)(D) REQUIRED Information System Activity Review PARTIALLY IMPLEMENTED

Implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports.

Evidence: #A1, #A2

4. EVIDENCE ARTIFACTS

Summarized with counts + exceptions + drill-down. Raw data available on request per retention policy.

#A1 Risk Register Review 2026-04-19T02:25:35.202960+00:00
Risk register present. 23 risks tracked. Last formal review 174 days ago (SLA: 90 days).
Records: 23 Exceptions surfaced: 0 Sampling: full enumeration
#A2 Sanction Policy Evidence 2026-04-19T02:25:35.202960+00:00
Sanction policy v2.1 approved 2025-12-01. 2 sanction events logged in HR system in last 12 months.
Records: 2 Exceptions surfaced: 0 Sampling: full
#A3 Audit Log Activity Review 2026-04-19T02:25:35.202960+00:00
Azure Activity Log + Sentinel reviewed. 340 admin actions over 90 days. 0 anomalies flagged.
Records: 340 Exceptions surfaced: 0 Sampling: 90-day window

5. TESTING PROCEDURES & RESULTS

Test of Design (does the control exist?) + Test of Operating Effectiveness (does it work consistently?). Sampling per AICPA AU-C 530.

Test of Design - Security management process documented DESIGN PASS
Sample size: n/a

ISP Policy v3.2 covers all 4 implementation specs.

Test of Operating - Quarterly risk review cadence OPERATING FAIL
Sample size: last 4 quarters

Only 2 of 4 quarters had formal risk review meeting. See Finding #1.

6. FINDINGS / EXCEPTIONS

Active findings: 1 · Accepted risks (exceptions): 0 · Total: 1

Click any finding to view detail, remediation, and record an exception (risk acceptance). Exceptions are retained in the report as part of the audit trail.

#8f330b376d86a7d8 MEDIUM risk-register Risk analysis review overdue by 84 days (last 2025-10-26, SLA 90d). ▾

7. MANAGEMENT RESPONSE

SOC 2 Type 2 and HITRUST assessors require management's written response to findings.

Management has reviewed 1 findings. Remediation on track per plan. Next review cycle: quarterly.

8. AUDIT TRAIL

ScannerTITAN AI Scanner v2.0 (CONDUCTOR + BASTION + SCOUT + COMPLY + SAGE)
Scanner versionv2.0.1
Collection timestamp2026-04-19T02:25:35.202960+00:00
Retention2555 days (HIPAA 164.316(b)(2))
Report hash (SHA-256)9ba0b9eec923e87a4ac18f41c49c3c01d1bce02a6c4fa74b6ca45428064383aa

9. CROSS-FRAMEWORK MAPPING

This same evidence is admissible for the following related controls. Scan once, satisfy multiple frameworks.